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UNITED STATES OF AMERICA. 



THE RULES 



OF 



ASEPTIC AND ANTISEPTIC 
SURGERY 



A PRACTICAL TREATISE FOR THE USE OF STUDENTS 
AND THE GENERAL PRACTITIONER 



/ c v 

BY 



PROFESSOR OF SURGERY AT THE NEW YORK POLYCLINIC \ VISITING SURGEON TO MOUNT SINAI HOSPITAL 
AND THE GERMAN HOSPITAL, NEW YORK 



AKPAD GfGEKSTEE, M. D. 

LESSOR OF SURGERY A 



;-> 



ILLUSTRATED WITH TWO HUNDRED AND FORTY-EIGHT ENGRAVINGS 
AND THREE CHROMO-LITHOGRAPHIC PLATES 




NEW YORK 
D. APPLETON AND COMPANY 

1888 



Copyright, 1888. 
By D. APPLETON AND COMPANY. 



PREFACE 



The object of this volume is a systematic yet practical presentation 
of the Listerian principle that has revolutionized surgery within the last 
fifteen years. Its adoption has wrought so many incisive changes in 
practice, has shifted the surgeon's standpoint regarding all the important 
disciplines of the art in such a radical manner, that most English text- 
books of surgery, even those recently published, have become partly or 
entirely inadequate to the wants of the modern physician. 

To a large number of medical men the aseptic and antiseptic methods 
present an incongruous chaos of seemingly contradictory and often in- 
comprehensible detail, arbitrary and varying, according to the predilections 
or whims of this or that teacher. 

Yet the principle involved is based on the correct observation of a 
common biological process — namely, that of the decomposition of organic 
substances. The well-known methods employed since the earliest dawn 
of civilization for the preservation of organic, especially animal, sub- 
stances, are based upon the empirical yet correct appreciation of the 
causes of putrefaction, and the practical adaptation of these methods to 
the healing of operative or accidental wounds contains the whole essence 
of the new surgery. 

Evils that former generations of surgeons deplored, but could not 
effectually combat, such as septicaemia, pysemia, hospital gangrene, and 
erysipelas, have been much abated, as a direct consequence of a clear 
understanding of their essential nature and causation. 

Prevention has become the watchword of modern practice, and it can 
be said that, by the successful employment of the preventive methods of 
the present day, surgery has become a conservative branch of the heal- 
ing art. 



iv PREFACE. 

The elimination of the accidental disturbances of repair caused by 
wound infection has depressed the percentage of mortality following 
amputation of the extremities from an average of thirty-five per cent to 
about fifteen per cent. 

The dread of undertaking and submitting to a surgical operation has 
greatly diminished, and timely — that is, early — surgical interference has 
become more and more frequent, to the great advantage of both patient 
and physician. 

As a direct consequence of the implied obligation of rendering timely 
aid where possible, a laudable eagerness for an early diagnosis is developed, 
and, there being so much to be gained by diagnostic knowledge, thorough 
and practical study of the morbid processes requiring surgical aid has 
been greatly stimulated. 

The fear of suppuration with its dreadful consequences does not stay 
now the hand of the surgeon as of old, when an operation was always 
considered a forlorn hope and a last resort. Strangulated hernise, for 
instance, are not allowed to gangrene as often as formerly, and herniotomy 
is readily resorted to, as it is well known that the dangers of an aseptic 
herniotomy done on a healthy gut are diminutive in comparison to the 
certain and enormous danger of strangulation itself. 

By the conviction that a fault of omission may be followed by irre- 
mediable mischief, the sense of responsibility is stirred up to vigilance, 
which again breeds self-reliance and firmness of purpose in advising and 
carrying out incisive measures, made clearly necessary by a well-recognized 
danger to life or limb. And an additional degree of responsibility is 
imposed by the very safety of aseptic operations. 

It can not now be successfully denied that the surgeon's acts deter- 
mine the fate of a fresh wound, and that its infection and suppuration 
are due to his technical fmdts of omission or commission. 

The principle underlying antiseptic surgery has ceased to be the 
subject of serious controversy. The author does not undertake to prove 
each of his statements to the satisfaction of those who look but see not. 
His object is instruction rather than controversy. Every one will have 
to pass his period of apprenticeship with its blunders and lessons. But 
he who becomes a master, to whom the primary healing of a fresh 
wound remains not a curiosity but becomes a matter of course, will not 
doubt the great change that has come over surgery. 



PREFACE. v 

The purely practical tendency of the work made a rather free ar- 
rangement of the several parts of the subject-matter a necessity, or at 
least a convenience ; yet a sufficiency of systematic order was preserved 
to give the collection of papers the character of a well-rounded, organic 
whole. 

The author begs to state explicitly that completeness — that is, the 
inclusion of all the disciplines of surgery — was not aimed at, else a com- 
plete text-book of surgery would have resulted. The leading idea, trace- 
able through all the matter contained in the book, is to illustrate the 
incisive practical changes that the adoption of aseptic and antiseptic meth- 
ods has wrought in surgical therapy. Hereby the changes in wound 
treatment are meant, as well as the notable extension of active surgery 
into fields formerly considered a noli me tang ere. 

As a consequence of the stupendous growth of operative surgery within 
the last decade, a fruitful development of operative technique is to be 
noted also. In accordance with the desire of the author to present to the 
profession a vivid and true picture of contemporaneous methods, the terms 
used as the title of this work should be accepted in their widest signifi- 
cance. 

Confinement to the meager details of those manipulations which, 
strictly speaking, constitute aseptic and antiseptic measures, would have 
yielded an inadequate and tedious compilation. On the other hand, it is 
hoped that the pathological and technical diversions, introduced for the 
sake of laying a rational foundation to the principles composing the 
essence of antiparasitic surgery, may be admitted as germane to the 
subject. 

The methods of wound treatment herein explained are to a certain 
extent still undergoing changes, hence should not be accepted as final. 
Yet it is undeniable that, as the clearness of the comprehension of the 
simple principle of asepticism applied to wound treatment has advanced, 
so the frequent changes and bewildering vacillation characteristic of the 
experimental stage of the new discipline have naturally given way to 
steadier methods. At present, changes are not so frequent as formerly, 
yet progress, especially the conquest of new fields for the legitimate prac- 
tice of active surgery, is not at a standstill. 

The author is well aware that the practical directions recommended 
by him are not the only ones that lead to success. Yet, in the main, he 



vi PREFACE. 

lias refrained from quoting other authorities. As reasons for this may be 
adduced, first, the disinclination to write a bulky text-book, and, further, 
the knowledge that the interest of the reader is proportionate to the 
directness and immediate character of the facts and thoughts contained 
in the work under perusal. 

As far as possible, all important statements will be found borne out by 
illustrative examples taken from the author's personal experience. 

The author is much indebted to the gentlemen composing the house 
staffs of the German and Mount Sinai Hospitals for the ready kindness 
and courtesy with which their help was proffered in tracing and extract- 
ing histories of cases, and in making the very numerous photographic 
plates that form the bulk of the illustrations. 

Great technical difficulties, inherent to the unfavorable season, the 
small space and inadequate lighting of the operating-rooms of the men- 
tioned hospitals, had to be overcome in exposing the sensitive plates. 
The matter was rendered still more difficult by the circumstance that 
operating and photographing were done by one and the same set of per- 
sons, and that the welfare and interests of the patients themselves had 
constantly to be sedulously considered. 

In view of the defective character of many of the author's negatives, 
the greatest praise belongs to Mr. William Kurtz, to whose artistic taste, 
skill, and versatility is due their excellent reproduction by phototypo- 
graphic process. 

Proper credit is given for the lithographic plates copied from Rosen- 
bach, for the excellent microphotographs reproduced from Koch's classi- 
cal reports, and for a few other illustrations borrowed from Esmarch, 
Henke, and Bumm. 

In conclusion, the author may be permitted to express the hope that, 
by publishing his share of experience gathered from a modest public and 
private practice, he may succeed to somewhat propagate and popularize 
the principles and practice of antiparasitic surgery. 

New York, September 3, 1887. 



CONTENTS. 



p AET I. —ASEPSIS. 

CHAPTER I. 



What are Sepsis and Asepsis ? 



PAGE 
3 



CHAPTER II 

Aseptic Wounds — Aseptic Treatment 
I. General remarks 
II. Rules of surgical cleanliness 

1. Hands 

2. The instruments . 

3. Wound irrigation 

4. Sponges 

5. Materials for ligatures and sutures 

6. Drainage-tubes and elastic ligatures 

7. Disinfecting lotions 

8. Dressings . 

(1) Types of dressings 

a. Simple exsiccation. Bismuth, iodoform 

b. Chemical sterilization combined with exsiccation. 

c. Schede's modification of the dry dress 

"the moist blood-clot 

d. Simple chemical sterilization. Moist dressings 

(2) Preparation of dressings 

a. Gauze .... 

(a) Corrosive-sublimate gauze 

(b) Iodoformized gauze 

b. Absorbent cotton, or common cotton batting 

c. Sawdust 

d. Moss . 

III. Practical application of rules 

1. In operating 

2. Change of dressings . 

IV. Aseptic measures in emergencies 

Operating bag and kit 



Dry dressings 
favoring the organization 



of 



10 
11 

11 
11 
12 

12 

13 
14 

14 
15 
15 
15 
16 
IT 
17 
17 
20 
23 
25 



CHAPTER III. 

Soiled Wounds. — Antiseptic Treatment. — Difference between Aseptic and Antiseptic 
Methods. — Illustration of Antiseptic Method ........ 27 



viii CONTENTS. 



CHAPTER IV. 

PAGE 

Special Rules regarding the Treatment of Accidental Wounds .... 29 

I. Temporary measures .29 

II. Definitive relief 31 

1. Contaminated wounds . 31 

2. Aseptic wounds .33 

3. Gunshot wounds 34 



CHAPTER V. 

Special Application op the Aseptic Method . . . ... . . 35 

A. General principles . . . .35 

I. Technique of surgical dissection 35 

II. Sutures 43 

III. Drainage .45 

h. Application of aseptic method to diverse organs and regions . .... 47 

I. Ligatures of arteries in their continuity 47 

II. Extirpation of tumors 50 

Preservation of asepsis .......... 50 

Safe removal ............ 50 

Complete removal , .50 

III. Amputation of limbs . . .59 

1. Aseptics and antiseptics of amputation ....... 59 

a. Clean cases 61 

b. Mildly septic cases 63 

c. Septic cases of greater intensity 64 

2. Haemorrhage 66 

a. Artificial anaemia 66 

b. Ligatures and final haemostasis 69 

3. Securing of a good stump . , -. . .71 

IV. Operations about non-suppurating joints 73 

1. Puncture and irrigation . . . . . . . . .73 

2. Arthrotomy 75 

a. Hydrops genu . . 75 

b. Vegetations 76 

c. Floating bodies of the knee-joint . . 77 

d. Suturing of the fractured patella 77 

3. Arthrotomy for irreducible or habitual dislocation, and for deformity due to 

fracture . 79 

V. Operations for deformities . 83 

1. Knock-knee and bow-leg 83 

2. Bony anchylosis in a vicious position 84 

3. Deformed callus ^ . . . .85 

4. Club-foot and pes valgus 85 

VI. Plastic operations . . . 88 

VII. Aseptics of the oral cavity 93 

VIII. Laryngeal operations 97 

1. Tracheotomy . . . 97 

a. Superior tracheotomy 99 

b. Inferior tracheotomy ........... 100 

2. Laryngofissure „.„..... 103 

3. Extirpation of the larynx ..,„»„, ... 104 



CONTENTS. 



IX 



PAGE 

IX. Goitre . .107 

X. Amputation of the breast 109 

XL Abdominal operations 115 

1. General remarks 115 

2. Herniotomy 117 

a. Herniotomy for strangulation 119 

b. Radical operation for hernia 128 

3. Laparotomy 133 

a. Exploratory incision 133 

b. Abdominal tumors 133 

(a) General remarks ' 133 

(b) Special observations .......... 140 

(a) Ovarian tumors . . . . 140 

()3) Supra-vaginal hysterectomy 143 

(y) Nephrectomy 145 

c. Gastrostomy ' . . . . . . . 146 

d. Colotomy 147 

(a) Lumbar colotomy . . . , 147 

(6) Inguinal colotomy 148 

XII. Hydrocele, varicocele, and castration . . 149 

1. Hydrops of the tunica vaginalis . 149 

2. Varicocele 151 

3. Castration - . . . . 152 

XIII. Aseptic operations on the rectum 154 

1. General observations 154 

2. Hemorrhoids 154 

3. Rectal tumors 157 

XIV. Aseptics of the bladder 159 

1. Catheterism 159 

2 Litholapaxy 161 

3. Cystotomy 162 

a. Perineal section 162 

6. Suprapubic section 163 



Part II.— ANTISEPSIS. 



CHAPTER VI. 



Natural History of Idiopathic Suppuration. — Treatment of Suppuration 
I. The cause of suppuration, or phlegmon 
II. Portals of infection 

1. Infection through lesions of the skin . 

2. Infection through lesions of the mucous membranes 

III. Entrance, progress, and localization of the infection . 

Mechanical irritation . . . ... 

Chemical and caloric irritation .... 

IV. Development of phlegmon 

V. Spread of suppuration 

VI. Diagnosis and treatment of phlegmon 



169 
169 
171 
171 
172 
173 
175 
176 
177 
179 
184 



x CONTENTS. 

PAGE 

1. General principles . ." . 184 

a. Superficial suppuration, or septic ulcer 185 

b. Cutaneous and subcutaneous phlegmon 185 

c. Deep-seated or subfascial phlegmon. Lymph-gland abscess . . .189 

d. Acute infectious osteomyelitis . . .191 

e. Chronic suppuration due to bone necrosis. Necrotomy . . . .194 

2. Phlegmonous affections of some special regions 208 

a. Face. Floor of the mouth. Neck. Temporal and mastoid regions . 208 

(a) Face 209 

(6) Neck .211 

(a) Fauces and pharynx 211 

()3) Submaxillary and parotid cynanche 217 

(7) Acute glandular abscesses of the anterior and lateral cervical regions 220 

(8) Glandular abscesses of the temporal, mastoid, and occipital regions 221 

b. Mammary and retro-mammary abscess 223 

c. Empyema 226 

d. Phlegmon of the palmar aspect of the hand, of the arm, and axilla . . 230 

e. Suppurative affections of the lower extremity 239 

(a) Ingrown toe-nail 239 

(b) Chronic ulcers of the leg 241 

(c) Acute suppuration of the prepatellary bursa 242 

(d) Acute suppuration of the knee-joint . • . . 242 

(e) Suppuration of the inguinal glands 245 

/. Perityphlic abscesses . . . . . . . . 246 

g. Abscess of the liver . 251 

h. Lumbar abscesses . . . 251 

i. Anal abscess. Fistula in ano 254 

CHAPTER VII. 
Erysipelas and Pseudo-Erysipelas . 259 



Part III.— TUBERCULOSIS : 
ITS ASEPTIC AND ANTISEPTIC TREATMENT. 

CHAPTER VIII. 

Natural History and Treatment op Tuberculosis 263 

I. Etiology of tuberculosis. Tubercle bacillus . 263 

II. Complication of tuberculosis with pyogenic or suppurative infection . . . 26*7 

III. Treatment of tuberculosis 267 

General principles 267 

Local treatment of tuberculosis . 268 

1. Cutaneous tuberculosis. Lupus 268 

2. Tuberculosis of the mucous membranes 269 

3. Tuberculosis of the lymphatic glands, or scrofula 269 

4. Tuberculosis of tendinous sheaths . - 271 

5. Tuberculosis of bone. Caries. Cold abscess ...... 273 

6. Tuberculosis of joints. White swelling ...... 275 



CONTENTS. xi 

PAGE 

General part . . . 275 

a. Technique of joint exsection ........ 275 

(a) Septic injection from without 275 

(b) Complete removal of tuberculous tissues 276 

(c) Control of haemorrhage . ... . . . 276 

(d) Preservation of function 276 

b. After-treatment . . . - . .277 

Special part 278 

a. Shoulder- joint 278 

b. Elbow . . . 280 

c. Wrist and hand ............ 284 

d. Hip-joint 285 

e. Knee-joint 287 

/. Ankle and foot .-.„.. 293 



Pakt IV.— GONOKKHCEA : 

ITS ANTISEPTIC TREATMENT. 

CHAPTER IX. 

Natural History and Treatment of Gonorrhcea 299 

I. Etiology of gonorrhoea. Gonococcus . . 299 

II. Treatment of gonorrhcea 301 

1. Acute gonorrhcea. Clap 301 

a. Anterior gonorrheal urethritis 302 

b. Deep-seated gonorrheal urethritis 304 

2. Chronic gonorrhoea. Gleet 307 

a. Inflammatory stenosis (incipient stricture) and permanent or cicatricial 

stricture of the urethra 307 

(a) Anterior urethra 307 

(6) Deep urethral strictures 313 

b. Vegetations of the urethra 315 

c. Granular urethritis . 815 

d. Chronic catarrh of the posterior part of the urethra, and chronic cystitis . 315 



p ART V.— SYPHILIS : 

ASEPTIC AND ANTISEPTIC TREATMENT OF ITS EXTERNAL LESIONS. 

CHAPTEE X. 

Aseptics and Antiseptics applied to External Syphilitic Lesions .... 321 

1. Aseptic treatment of primary induration 321 

2. Antiseptic treatment of the primary syphilitic ulcer . . . . . 324 
a. Chemical sterilization and surface-drainage by medicated moist dressings 324 

6. Chemical sterilization by strong caustics 325 

c. Sterilization by the actual cautery . . . . . . . . 326 



PART I 



ASEPSIS 



CHAPTER I. 

WHAT ARE SEPSIS AND ASEPSIS? 

It is not intended here to enter into an exhaustive exposition of the 
essence of suppuration and the whole complex of conditions known under 
the name of sepsis. It may suffice for the present to give a rough out- 
line of the views that prevail regarding the causation of the conditions in 
question. 

Albuminoid substances, such, for instance, as blood or blood-serum — 
in fact, all the tissues of the dead animal body — will become putrid under 
certain well-known conditions. These are, first, moisture ; secondly, a cer- 
tain temperature called warmth, for short; and, thirdly, the presence of 
living organisms, or fungi, named schizomycetes, better known under the 
name of bacteria and micrococci. If all these conditions are present, the 
animal substance in question will ferment or putrefy. Absence of any one 
of these conditions will be sufficient to prevent decomposition. To illus- 
trate this proposition, we shall mention common facts. Fresh meat or fish, 
well dried, can be indefinitely preserved ; freezing and, to a certain extent, 
roasting will also prevent its spoiling ; and, lastly, exclusion of micro- 
organisms by air-tight packing or sealing, after boiling, will insure preserva- 
tion for an indefinite length of time. 

The active agents of decomposition are the micro-organisms, which will 
develop at once their disintegrating activity as the conditions favorable to 
their develojmient (moisture and a certain temperature) are present. 

We then either thoroughly dry the substance to be preserved or produce 
and preserve a very low or very high temperature in it, all of which will pre- 
vent the development of fungi. Exclusion of the fungi is herein unneces- 
sary. The third mode of preservation is that employed in canning meats. 
They are first boiled thoroughly, then the vessel wherein this boiling was 
done is hermetically sealed while the substance is still very hot. Here we 
have a combination of first destroying the vitality of such fungi as are con- 
tained in the meat before boiling, and, secondly, exclusion of access of new 
micro-organisms to the sterilized substance. 

Note. — The most effective sterilizer is the actual cautery. It not only destroys all the nox- 
ious germs contained within the tissues, but at the same time provides these with an often dry 
and always hermetic seal against further infection. If the eschar and its vicinity be well dusted 



4 EULES OF ASEPTIC AND ANTISEPTIC SUEGEEY. 

with iodoform-powder, it will often happen that complete cicatrization will take place beneath 
its protection, even before the detachment of the eschar. 

An accidental or surgical wound presents conditions that are eminently 
favorable for the development of the fungi in question. The oozing blood 
and lymph, the bruised and dead cells of the various exposed tissues, fur- 
nish, severed from their natural connections, the moist pabulum of a proper 
temperature. The myriads of particles of filth or dust, filling the air in all 
inhabited localities, contain, according to indubitable evidence, a very large 
proportion of spores or seeds that, on falling upon the wound and its secre- 
tions, promptly develop into fungi, and at once set up a fermentative process 
known as decomposition. 

The products of this fermentation are more or less highly poisonous sub- 
stances — Bergmann's sepsin, or the ptomaines of the French authors. They 
promptly set up local changes in the shape of inflammation, and cause sys- 
temic trouble — that is, septic fever. 

It is further necessary for us to know that in septic processes of a wound 
not only the ptomaines are absorbed by the lymphatics, but that often an 
actual invasion of the living tissues by the fungi will take place, and that 
the lymphatics and veins will also serve as channels for the importation of 
dangerous quantities of fungi into the circulation. Secondary deposits, 
metastases, will then easily occur. 

Clinical observers properly distinguish between different, more or less 
intense forms of septic infection, in which bacteriology, however, does not 
always demonstrate correspondingly different forms of fungi. On the other 
hand, it is known that impoverished nutrition, but especially a certain mor- 
bid state, namely, diabetes mellitus, presents an extremely favorable con- 
dition for the development of bacterial sepsis. 

Regarding syphilis and tuberculosis, this can not be said, as it is not 
difficult in these conditions to prevent suppuration of accidental or surgical 
wounds. 

Case. — In 1879 the author removed from the lumbar region of a young brewer a 
good-sized lipoma. His skin was covered at the time with a recent syphilitic roseola 
following a chancre. Under ordinary antiseptic precautions prompt union by the first 
intention followed, although the treatment was altogether ambulatory, the patient 
having been operated on and treated throughout at the German Dispensary. 

Prompt primary healing of the wounds caused by the extirpation of syphilitic buboes 
is a rather common experience in the syphilitic ward of the German Hospital. 

The excellent results obtained after exsections of tuberculous joints are also proof 
positive of the assertion that tuberculosis in itself does not dispose to suppuration and 
sepsis, and that prevention of septic processes in the wounds of the victims of tubercu- 
losis is not difficult. 

Diabetes mellitus, however, does undoubtedly heighten the disposition to septic 
conditions. Ordinary antiseptic precautions often fail to prevent suppuration ; hence, 
an injury, or the necessity of a bloody operation in a diabetic, should never be treated 
lightly. 

It is the immortal achievement of Lister to have first attributed to fer- 



AKKPTIO WOUNDS ASEPTIC TREATMENT. 5 

mcntativc influences fche disturbances of repair, and to have led wound- 
fcreatment into a rational, hence successful, direction. 

Modern wound-treatment is based entirely on the old and well-known 
principles of the preservation of organic substances. Of the several modes 
of preservation, freezing is the only one that is inapplicable in human sur- 
gery. Exsiccation, however, and burning with the actual cautery (roust- 
ing) ; then chemical sterilization by germicides, and the combination of 
chemical sterilization with exsiccation, contain the essence of aseptic sur- 
gery. They insure wounds against decomposition, and are a secure pre- 
ventive of suppuration. 



CHAPTER II. 

ASEPTIC WOUNDS— ASEPTIC TREATMENT. 
I. GENERAL REMARKS. 

Supposing that the skin in the region to be operated on be shaved, then 
energetically scrubbed in hot water with soap and a clean brush for five 
ininutes, then the surgeon's hands be scrubbed, likewise his knife, and now 
an incision be made through the skin ; supposing that this happen in an 
atmosphere free from particles of dry filth called dust : such a wound could 
be safely termed a clean or aseptic one. All particles of filth adhering to 
skin, hands, and instrument were removed by this simple process of scrub- 
bing, and no new particles could settle down out of the atmosphere, which 
we assumed to be free from dust. 

Experience has taught that such a wound, however large, will heal 
without suppuration, first, if its edges be approximated by sutures made 
with a clean needle; and (dean wire, silk, or gut; and, secondly, if the im- 
munity from an invasion of filth be maintained until the bloody scrum 
marking flu; line of union become dry. 

But we can vary our experiment, and show that a wound can heal with- 
out suppuration even if contact of the walls of the same be imperfect or 
none. 

(Use. — Mrs. J. R., aged forty-nine; branchial cyst of the submaxillary region of the 
size, of an orange. Had been punctured a number of times. Oct. 7, 1882. — Incision of 
six inches in length ; difficult extirpation. The large vessels of the neck were freely 
exposed, a considerable affluent of the deep jugular vein was deligated. Catgut used was 
rather brittle. Suture and drainage of the large wound. Antiseptic dressings. Imme- 
diately after the operation patient had a severe coughing spell. Oct. 12. — On changing 
the dressings it was found that the interior of the wound was distended by a massive 
blood-clot, giving an appearance as though the tumor had not been removed at all. 
8 



6 KULES OF ASEPTIC AND ANTISEPTIC SURGEKY. 

Sanguinolent serum was discharging from the drainage-tube. Dressings renewed. 
Oct. 16. — Tumor much diminished in size. Drainage-tube removed. Oct. 20. — 
Wound firmly healed; outline of neck normal. Throughout, normal temperatures. 

Here we see that undoubtedly secondary venous haemorrhage had taken 
place into the large cavity of the wound. The distention did not reach a 
sufficient degree to produce a rupture of the line of sutures. The enormous 
clot was rapidly absorbed, and the wound healed without suppuration, 
though not by primary adhesion. If the wound had not been aseptic, 
putrefaction of the clot and dangerous septic processes would have inevit- 
ably followed. 

Still more curious is the course of an aseptic wound that is not united 
at all, but is left gaping, provided that suitable means are employed to 
preserve its aseptic character. 

Case. — Mrs. 0. T.. aged forty-three, came from Ohio to have a syphilitic defect of the 
nose repaired. Total rhinoplasty, Sept. 18, 1883, at Mount Sinai Hospital. A suitable 
flap containing the periosteum was raised from the forehead. The edges of the frontal 
wound could not be drawn together, therefore a properly shaped, well-disinfected 
piece of rubber tissue was laid on it, and this was covered with an iodoform dressing. 
Sept. 23. — Stitches removed from nasal sutures. Dressing on forehead dry, therefore 
it was left undisturbed. Oct. 1. — Dressing of frontal wound being removed, the rubber- 
tissue covering became visible ; after this was taken away the edges of the wound 
were found to be cicatrized to the width of half an inch on both sides. A moist, 
fresh-looking remnant of the blood-clot was still covering a strip of the middle of the 
wound. No suppuration whatever. Dressings renewed. Oct. 6. — Entire wound 
cicatrized with the exception of a spot as large as a penny at the upper end. Oct. 10. 
— Discharged cured. 

Here, then, is an example of the now commonly observed fact that a 
gaping defect will cicatrize over without suppuration if putrefactive changes 
be excluded from the clot filling up the gap. This observation involves a 
radical difference from the old tenet that whatever wound does not heal 
by primary adhesion must heal by suppuration. A third possibility ha& 
become demonstrable, for which older pathology had no exjdanation. 

It is necessary to state that in both of the latter examples the condition 
of a dustless atmosphere during the time of the operation was not present j 
the operations were done in ordinary rooms, openly communicating with 
the dusty streets of New York, yet the behavior of the wounds was per- 
fectly correct. 

The extreme difficulty of preparing and maintaining a dustless atmos- 
phere in a room of an inhabited locality is well known to everybody, and, 
as a matter of fact, the general practitioner must and will have to do his 
surgery in more or less dusty rooms. Since the procurement of this con- 
dition is practically unattainable, frequent irrigation or rinsing of the 
wound becomes a necessity. But even a constant and powerful stream of 
fluids will not be able to dislodge all the particles of dust that may have 
settled down upon and insinuated themselves into the nooks and crevices 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 7 

of a wound. Hence it is desirable to employ a liquid that, aside from its 
non-irritant quality, will have the property of neutralizing or rather 
extinguishing the noxious effects of those particles of dust that can not 
be washed away by the irrigation, but remain imbedded in the tissues. 
This is chemical sterilization. 

Different disinfecting solutions are used for this purpose to answer 
various requirements. Their composition and uses will be mentioned here- 
after. 

Note. — Kiimmel, of Hamburg, has shown that a dustless operating-room can be had in a 
well-appointed hospital, and Neuber, of Kiel, has excellent results from operations done in such 
a dustless room, with well-cleansed hands, apparatus, and instruments, without, the employment 
of antiseptic fluids. Even the dressings used are not impregnated with any antiseptic chemical, 
but are merely "sterilized" by being exposed to dry heat. No sponges are used, all blood 
being removed with a sterilized solution of common salt (6 : 1000), which is absolutely unirri- 
tating, and certainly forms the most gentle manner of cleansing a wound. 



II. RULES OF SURGICAL CLEANLINESS. 

1. Hands. — The hands and forearms, especially the finger-nails, of the 
surgeon and his assistants should be well scrubbed in hot water with soap 
and brush for five minutes ; likewise the region of the body of the patient 
to be operated on after carefully shaving off the hair. After this follows an 
immersion of the hands in corrosive sublimate lotion for one minute. 

Note 1. — Kiimmel's recommendation of green soap (potash or soft soap) is excellent, on ac- 
count of its great solvent properties. 

Note 2. — Rings, especially those having stone settings, should never be worn by the surgeon 
or his aids in an operation. Bangles, and bracelets of female nurses should not be tolerated. 
Every one's arms should be bared and scrubbed to the elbows. 

2. The instruments should be subjected to a careful and minute cleans- 
ing with soap and brush, especial care being taken to remove dry particles 
of blood, pus, etc., from the grooves and behind the clasps of the more com- 
posite instruments, which ought to be taken ajoart each time for cleansing. 
They should be immersed for ten minutes in a three-per-cent solution of 
carbolic acid before use. 

Note. — The surgeon should learn to get along with as few instruments as possible. In 
selecting instruments, preference should be given to the most simple. The best instruments are 
those having smooth and well-polished surfaces ; grooved or roughened handles are hard to clean 
and unnecessary. 

3. Wound Irrigation. — During the operation the wound should be fre- 
quently irrigated with the proper kind of a disinfecting fluid ; the hands 
of the surgeon and his assistants should be also washed at not too long 
intervals in a disinfecting fluid (corrosive sublimate, 1 : 1000) ; the instru- 
ments should be kept immersed in a three-per-cent solution of carbolic 
acid (which is the least injurious to them). 

Note. — Whenever any one of those engaged at an operation touches a not disinfected object 
— hands a chair, opens the window or door, helps the ansesthetizer during a vomiting spell of 



8 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

the patient, scratches his face, or wipes his nose — it is absolutely necessary that his hands be 
scrubbed and disinfected anew. Instruments that are accidentally dropped should be left un 
touched. Raw assistants, and especially nurses, male and female, trained or untrained, should be 
earnestly instructed beforehand, and constantly watched afterward, regarding this all-important 
discipline. 

4. Sponges should be beaten free from calcareous particles, then im- 
mersed for fifteen minutes in dilute muriatic acid to dissolve the remnant 
of lime, washed in cold water, then thoroughly kneaded by hand with green 
soap in hot water for five minutes, rinsed, and then immersed in a five-per- 
cent solution of carbolic acid, in which they remain until required for use. 
Sponges used once in an aseptic operation can be used again. Careful wash- 
ing out with green soap and hot water of all the remnants of fibrin and 
blood, then immersion in a five-per-cent solution of carbolic acid, is suffi- 
cient. It is not good to use too many sponges at an operation. When sat- 
urated with blood at an operation, they should be washed free from it in 
hot water, then thrown into a basin filled with carbolic solution, and hence 
handed to the surgeon. Carbolic acid is preferable for preservation of 
sponges until use, because it does not become decomposed and inert, as, for 
instance, corrosive sublimate. 

Note. — Selected Florida sponges are cheap and good. In New York a pound can be bought 
for about two dollars, each sponge costing on an average two cents. 

5. Materials for Ligatures and Sutures.— Well-prepared catgut of differ- 
ent thicknesses will answer every purpose for ligatures and sutures. The 
finest suture work on the intestines can be neatly and reliably done with 
catgut No. 0. The most massive pedicle can be safely tied with catgut No. 
4. For ordinary ligatures and sutures, No. 1 will be most convenient, and 
should constitute the bulk of the surgeon's supply. 

The simplest way of preparing catgut is Kocher's : Immerse catgut for 
twenty-four hours in good oil of juniper (ol. juniperi baccarum, oil of the 
berry, not the oil gained from the wood) ; transfer into and preserve in 
absolute alcohol until use. Alcohol keeps catgut hard and firm, yet flexible. 
Carbolic acid or corrosive sublimate will make it brittle and weak. Where 
it is desirable to prevent too early absorption, as, for instance, in intestinal 
sutures, a hardening process should be added to the disinfection. The arti- 
cle should be washed in alcohol, then placed into a quart of a five-per-cent 
solution of carbolic acid containing thirty grains of bichromate of potash. 
Forty-eight hours' immersion will produce catgut that will resist the action 
of the living tissues for a week or longer. Large-sized catgut needs a longer 
immersion. Wind up on bobbins. 

Note 1. — Good catgut can be procured from L. H. Keller & Co., 64 Nassau Street, New 
York, for a moderate price. Dry preservation makes catgut more suitable for transportation : 
Immerse the prepared article for five minutes in ether, 100 ; iodoform, 5. Take out and place in 
a well-corked, wide-mouthed bottle. A film of iodoform will cover each thread. 

Note 2. — The author observed once unmistakable. wound infection by improperly kept catgut. 
Case. — Jenny Marks, servant-girl, aged twenty, admitted November 10, 1883, to Mount Sinai 
Hospital with habitual subcoracoid dislocation of the right shoulder-joint. " Sprain " had been 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 9 

diagnosticated by a physician, seven weeks previous to her admission, who ordered a liniment, 
On admission, reduction was easily effected by manipulation, but the weight of the limb was suf- 
ficient to reproduce the dislocation. A pi aster-of -Paris jacket, inclosing the reduced arm, was 
applied and worn for four weeks without any effect. Dec. 11th. — The joint was freely opened 
by an anterior longitudinal incision, when it became evident that the tendency to dislocation was 
due to laxity or redundancy of the anterior part of the capsular ligament. By two semi-ellipti- 
cal incisions, a piece of the capsule one inch long and half an inch in width was removed. The 
capsular as well as the muscular and the skin wound were united by three tiers of interrupted 
catgut sutures, a drainage-tube having previously been carried just within the capsule. The 
next day moderate fever (101° Fahr.), but great dejection, headache, and vomiting were observed 
the patient complaining of much pain in the joint. Dec. 13th. — The thermometer indicated 
103° Fahr., with a corresponding increase of the general disturbance. The patient was anaes- 
thetized, and the wound was exposed. No redness, only slight cedema was visible. The wound 
was reopened. Firm agglutination was present everywhere except in four places, where swollen, 
discolored ligatures applied to the circumflex artery and some smaller vessels were seen sur- 
rounded by a halo of yellowish, semi-fluid, broken-down tissue, evidently representing small 
abscesses that were forming about the catgut ligatures. They were removed, the Avound was 
irrigated with carbolic lotion, and packed with gauze. The fever fell off at once, and no further 
complication interrupted the course of healing. The habitual luxation was also cured. 

Silk can also be rendered unirritant by boiling it for an hour in a five- 
per-cent solution of carbolic acid (Czerny), then preserving in alcohol. 

Silk-worm gut is excellent material for suturing. It is prepared like 
silk, and before use should be soaked awhile in carbolic lotion to make it 
supple. Its advantage : it is easy to thread. 

6. Drainage-tubes and elastic ligatures are cut into proper lengths— that 
is, a little shorter than the height of the wide-mouthed bottle in which they 
are kept. This is filled with a five-per-cent solution of carbolic acid, that 
should be renewed from time to time. The tubes will always occupy an 
upright position in the bottle, and can be taken out easily. 

Note. — Rubber tubing of black material is preferable to the coarser and unyielding white 
stuff, on account of its softness and pliability. 

Theoretically speaking, a perfectly aseptic wound does not require any 
drainage. If the secretions following an operation or injury do not contain 
anything that is capable of inducing putrid changes, they will be absorbed, 
and will not cause any disturbance in the wound or the general health. The 
large blood-clot around a fractured bone is harmlessly absorbed ; a large 
blood-clot in an aseptic operation wound will be also absorbed without local 
or general disturbance, as Mrs. B.'s case (see page 5) has shown. The 
experienced surgeon who has mastered the technique of asepticism will not 
hesitate to close up without drainage a small wound, as, for instance, after 
deligating the subclavian or iliac arteries. But, in operations where large 
surfaces were long exposed, and where the wouud is very irregular, the pos- 
sibility of a however slight and unavoidable contamination should always 
be kept in view. Vents should therefore be provided in the shape of prop- 
erly placed drainage-tubes for the easy egress of secretions, possibly contain- 
ing elements of future decomposition. If the healing be prompt, the tubes 
can be withdrawn on the fourth or sixth day. In case of suppuration, 
bland or destructive, they will be in place, and very opportune. 



10 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

7 A Disinfecting Lotions. — With a few exceptions (very large wounds 
requiring prolonged irrigation, and in operations involving the peritoneum), 
two lotions will be found sufficient. For the immersion of the instruments, 
a three-per-cent solution of carbolic acid, and for the irrigation and disin- 
fection of hands and skin, a solution of corrosive sublimate of 1 : 1,000 — 
1,500. 

Note. — The almost exclusive use by the author of carbolic acid and corrosive sublimate 
as germicides is intentional. It was determined by the fact that these substances are, first, 
thoroughly reliable and highly effective ; secondly, procurable almost everywhere, in the 
country store as well as in the city ; thirdly, because adherence to certain carefully selected 
substances results in a thorough knowledge of their proper use under varying conditions. 

Boiled water is preferable as a solvent. It alone would be no doubt suf- 
ficient if we were absolutely sure against the introduction of filth into the 
wound. 

Note. — A ready and handy way of mixing the lotions is the following one : 
Carbolic Acid. — One tablespoonful or four teaspoonfuls to a quart bottle of hot water will 
make a lotion of the strength of about three per cent, reckoning 650 grammes to the ordinary 
wine -bottle. 

Corrosive Sublimate. — Keep on hand a few ounces of an alcoholic solution of the salt of 1:10 
in a glass-stoppered bottle (in boxwood case for transportation). One teaspoonful of this added 
to a quart bottle of hot water will make about a 1 : 1,500 solution, which can be weakened by 
dilution. The addition of one teaspoonful of cooking-salt will prevent disintegration of the mer- 
curic preparation. 

Boro- Salicylic Lotion. — In cases where carbolic or mercurial poisoning 
could be produced by the use of mercuric or carbolic irrigation, Thiersch's 
solution is commendable as a substitute. It consists of salicylic acid 2, 
boracic acid 12, and hot water 1,000 parts. It is non-poisonous, very bland, 
and the peritoneum can be washed with it with impunity. External wounds 
of large size should be also irrigated with this lotion. A final thorough 
irrigation with corrosive sublimate should sterilize the wound before clos- 
ing it. 

Note. — The selection of different lotions should be governed by the following experiences : 
Carbolic lotions are dangerous to small children, even in great dilution, and should never be used 
on them. Corrosive sublimate is also poisonous, causing salivation, and occasionally fatal diph- 
theritic inflammation of the ileum and the thick gut, if its use is immoderate. Wherever super- 
ficial ulcers or inflammations of the cuds require the antiphlogistic action of the very diffusible 
carbolic lotion, it should be employed in the strength of two or three per cent. The continued 
use of higher concentrations will corrode the tissues, and is otherwise dangerous. 

Where a direct application of the lotion to the wounded or diseased surface is desirable, as, 
for instance, in all bloody operations, mercuric bichloride deserves the preference over carbolic 
acid. Even weak solutions (as 1 : 5,000) have a decided germicidal power, and can be used on 
very extensive wounds for hours without serious danger of intoxication. The final irrigation of 
an operation wound should always be done with a stronger (1 : 1,000) solution. Abscess cavities 
will always require the stronger solutions. 

The greatest advantage of corrosive sublimate over carbolic acid is, however, to be sought in 
its different effect upon the fresh blood-clot and the tissues exposed to its action in a fresh wound. 
It will be seen that irrigating an amputation wound, for instance, with carbolic lotion, will each 
time provoke very profuse oozing. Vessels that had stopped bleeding by the formation of a clot 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 11 

within their cut orifices begin to bleed anew after cai'bolic irrigation. This is caused by the 
peculiar macerating effect of carbolic acid upon the fresh blood-clot. Its color turns from dark 
red to a light brick-red, its toughness and cohesion are lost, and the slightest touch of a sponge 
will suffice to detach it from the orifice of cut vessels, thus renewing the haemorrhage. Another 
disagreeable effect of carbolic lotions upon wounds is the profuse discharge of bloody serum 
continuing for one or two days after the operation, rendering one or more changes of dressings 
necessary within a day or two, and thus depriving the wound of needed rest at the most critical 
period of repair. 

Corrosive sublimate does not dissolve clots, hence oozing stops by natural means during its 
use. It does not irritate the vaso-motor nerves as carbolic acid seems to do, hence the oozing 
subsequent upon an operation done with its aid is very scanty. Drainage is easier, can often be 
altogether spared ; no early change of dressings is required, and cure under one dressing is possi- 
ble, and, in fact, is the rule after its proper use. 

8. Dressings. — We have mentioned that there are two ways of preserving 
the aseptic character of a wound, viz., by exsiccation or by sterilization of 
the secretions. These two methods can also be advantageously combined. 



(1) Types of Dressings. 

a. Simple Exsiccation. — Small, or comparatively small wounds, ad- 
mitting of an exact coaptation of the deeper as well as their superficial 
parts by suture, are exquisitely fit for this method of treatment. Plastic 
operations about the face may serve as a fair type. 

Bismuth and Iodoform. — Certain finely powdered substances, as iodo- 
form or subnitrate of bismuth, have the quality of rapidly inspissating blood 
and serum to a dry crust. Accordingly, after the haemorrhage has been 
controlled and the wound closed by suture, a quantity of the substance 
chosen is dusted over the sutures. No further dressings are applied. The 
escaping bloody serum forms a paste with the powder, which by its steriliz- 
ing property prevents decomposition, while the paste remains moist. Free 
access of air will hasten exsiccation, and the dry, hard crust once formed 
will securely prevent further ingress of dust into the wound. In cases 
where the powder is washed away by profuse oozing, the dusting has to be 
repeated every half-hour after the operation, until the object — the forma- 
tion of a dry crust — is accomplished. 

Note. — Elderly subjects are prone to iodoform poisoning if the agent is too freely used. In 
these cases a mixture of equal parts of iodoform and bismuth is safer. 

Small cuts, abrasions, and burns can also be similarly treated, care being 
taken to first render the injuries aseptic by ablution with corrosive subli- 
mate lotion. 

Note. — Acetic Acid. — An excellent way of treating small injuries is to wash them as soon as 
possible — after staunching the haemorrhage — with pure acetic acid ; or, if this can not be pro- 
cured, with ordinary vinegar. The intense smarting is soon controlled by the application of cold 
water. After this the part is dried with a towel. The dry but flexible eschar produced by the 
union of the acid with the exposed tissues gives excellent protection, under which the wound 
heals without reaction or suppuration. The great advantage of this form of treatment will be 
especially appreciated by physicians, as the eschar is insoluble, and the injured or chapped hands 



12 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

treated in this manner can be washed repeatedly without compromising repair or risking new 
infection by contact with pus. 

More extensive burns or denudations are, within reasonable limits, also 
adapted to the exsiccative treatment. However, to prevent injury of the 
granulations at change of dressings, due to their matting into the meshes 
of the gauze, protecting the burned surface by a layer of rubber tissue will 
be found very useful and commendable. But the larger the absorbing sur- 
face, the more caution is needed in the use of iodoform. 

b. Chemical Sterilization combined with Exsiccation. Dry 
Dressings. — In extensive injuries or large operation wounds the amount 
of oozing is generally so large that dusting alone will not suffice to control 
decomposition. Besides the patient's person, the bedding or splints will be 
uncomfortably soiled ; hence it is necessary to provide a receptacle for the 
absorption of the secretions. For this purpose absorbent dressings are used 
that have been rendered aseptic by saturation with a chemical germicide : 
iodoform, corrosive sublimate, or carbolic acid. A small surplus of the 
chemical used will suffice to prevent decomposition of the absorbed serum 
or blood. No impervious covering (Mackintosh) should be used on the 
outside of the dressing, as the free admission of dustless air is desirable. 
It will hasten the exsiccation of the absorbed secretions, and thus insure 
the protective action of the dressings, even if the chemical employed become 
evaporated or inert. As evaporation of the deepest parts of the dressing — 
those nearest the skin and farthest from the surface — is the most difficult, 
and is made still more difficult by their greater saturation with serum, a 
few layers of iodoformized gauze placed immediately over the line of union 
will be of very great service in hastening exsiccation. These are covered 
with an ample mass of dressings impregnated with corrosive sublimate, 
which are held down with a roller bandage. 

This is the method of dressing most commonly resorted to nowadays, 
and has been found the most simple and effective by the majority of modern 
surgeons. 

c. Schede's Modification of the Dry Dressing, favoring the 
Organization of the Moist Blood-Clot. — There is a considerable num- 
ber of cases where extensive loss of substance consequent upon an injury 
or an operation precludes approximation of the walls of the wound, and 
renders healing by primary adhesion impossible. In these cases a blood- 
clot forms and fills up the defect soon after the injury or the operation. 
In an aseptic wound this blood-clot serves a highly useful purpose in pro- 
tecting the raw surfaces, preserving their vitality, provided that the integ- 
rity of this blood-clot be again protected from exsiccation on one and from 
putrefaction on the other hand. If this condition is fulfilled, granulations 
will gradually consume, as it were, the blood-clot ; and, by the time the clot 
disappears, cicatrization will be completed. When healing under the moist 
blood-clot is aimed at, the dressings will, have to be arranged as follows: 
Immediately over the wound is laid a suitably trimmed piece of fine rubber 
tissue, previously well soaked in carbolic solution. It should just overlap 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 13 

the edges of the wound. This is covered with a layer of iodoformed gauze, 
and the whole is well enveloped in an ample covering of dry corrosive sub- 
limate gauze. The outer dressings will absorb and render innocuous the 
surplus of blood and serum ; the film of rubber tissue will preserve the 
underlying clot in a moist condition. 

Note. — Tissues of low vascularity, as bone, fasciae, and tendons, will certainly undergo 
superficial or deep-going necrosis if exposed to evaporation, even if asepsis be rigidly preserved. 

Case. — George Braun, German Hospital, aged sixty-six." Rodent ulcer of the nose. Feb. 
19, 1886. — Extirpation of diseased parts followed at once by partial rhinoplasty. Sutured parts 
dusted with iodoform. Large defect on forehead (the flap including periosteum) inadvertently 
covered with iodoform gauze, without interposition of rubber-tissue protective. When the 
dressings were removed ten days later, no suppuration was found, but the surface of the frontal 
bone was seen to be exposed (no blood-clot), and very dry. After four weeks the first sparse 
granulations were observed sprouting out of the denuded bone, which eventually became cica- 
trized over in the fall of the same year. Had the protective not been omitted, rapid cicatriza- 
tion would have been secured. 

d. Simple Chemical Sterilization. Moist Dressings. — A moder- 
ately moist condition of the outer dressings is very favorable to rapid ab- 
sorption. This fact is parallel with the phenomenon seen if a thoroughly 
dry sponge is thrown on water. It will not absorb rapidly and sink, but, 
on the contrary, will float on the surface for a considerable period of time. 
But moisten this sponge first thoroughly, then squeeze it out completely, 
and then throw it into water, and it will at once become filled and sink. 
Where rapid absorption is desirable, as in the presence of septic or fetid 
discharges, and where clogging of the drainage-holes by inspissated secre- 
tions is to be avoided, dry dressings will be advantageously replaced by a 
moist dressing. By applying a piece of impermeable material to the out- 
side of the well-moistened dressings, evaporation and exsiccation will be 
prevented, and the dressings will remain in a moist condition for an indefi- 
nite period of time. 

Rubber tissue (not rubber sheeting) is an excellent and cheap substitute 
for Lister's "Mackintosh" and his "protective." It can be had in all 
rubber stores. A rather stout quality is the best article, as it is not apt to 
tear, and can be repeatedly used as the outer covering of moist dressings. 
It always forms the outermost layer of what is called throughout this book a 
"moist dressing.'" Oiled silk, well soaked in carbolized lotion, is a toler- 
able substitute for rubber tissue. Another substitute is waxed paper, or 
"tracing paper." A piece of stout, brown paper, such as is used by shop- 
keepers for packing, well soaked in grease, preferably tallow, will answer 
on a pinch. If none of these articles can be had, frequent moistenings of 
the dressings will have to be employed in order to prevent evaporation. 
One or more teaspoonfuls of carbolic or mercurial lotion instilled into the 
dressings every half-hour or so will have the desired effect. This form of 
moist wound-treatment was very extensively employed by the author in his 
seven-years' service at the German Dispensary, and has been found so satis- 
factory both to patients and surgeons that it is still the standard form of 

moist dressing used at that institution. 
4 



14 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



(2) Preparation of Dressings. 

a. Gauze. — Gauze, called in the trade cheese-cloth, or tobacco-cloth, 
forms undoubtedly the most convenient material for wound-dressings. It 
is cheap, can be bought everywhere, absorbs well, is soft and pliable, and 
can be easily prepared for use by every practitioner. For hospital pur- 



14 in. 



14 in. 



UPPER AND 
LOWER EXTREMITY, 
HIPJOINT. 
TRUNK. 



r 



HERNIOTOMY, 



SCROTUM. 



SHOULDER \) UOINT. 
AXILLA. 
ANKLE /\ UOINT. 




14 in. 



19 in. 



19 in. 



AXILLA 



AND BREAST. 



28 in. 



LOWER EXTREMITIES. 



EXSECTION OF 



SHOULDER UOINT. 



AMPUTATION 



OF THIGH. 



19 in. 




28 in. 28 in. 

Fig. 1. — Patterns for various dressings, modified from Neuber. 

poses, moss or peat dressings in the shape of cushions or bags are more 
convenient. In the practice of the country physician, however, they are 
out of the question. 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 



15 



(a) Corrosive Sublimate Gauze. — The raw gauze is treated as follows : 
To free it of its oily contents, and thus to make it more absorbent, 
twenty-five yards of the fabric are boiled for an hour in a wash-kettle filled 
with sufficient water to cover the material, to which should be added two 
pounds of washing-soda or a pint of strong lye. After this the stuff is 
washed out in cold water, passed through a clothes-wringer, and immersed 
in a sufficient quantity of a 1: 1,000 solution of corrosive sublimate for 
twenty-four hours, then passed again through a clothes-wringer, dried, and 
put away in a well-covered glass jar until required for use. 

The fabric is so folded by the manufacturer that each fold is just one 
yard long. It is best to divide the twenty-five yards into segments of about 
six yards each, which can be again folded by the surgeon into large or small, 
square, oblong, or narrow compresses to suit each individual case. If a 
long time has elapsed since the preparation, reimpregnation with a 1 : 1,000 
solution of corrosive sublimate is advisable before use. 



Note. — In a small proportion of cases, contact with corrosive-sublimate dressings will cause 
an angry-looking dermatitis, which at the first blush very closely resembles erysipelas. The 
absence of fever and sickness, the exact limitation of the rash by the extent of the dressings, 
will soon disperse possible doubts. Profuse application of vaseline 
or some other bland ointment will readily dispose of the irritation. 
The strength of the impregnation should be then also reduced by 
washing the gauze in water. If it should be found that mercury is 
not borne at all, it should be substituted by carbolic-acid solution or 
Thiersch's boro-salicylic lotion. 

(b) Iodoformized Gauze. — The moist, absorbent 
gauze is evenly sprinkled with iodoform powder from 
a pepper-box, or the author's iodoform duster, well 
rubbed into the meshes by hand, and then put away 
in a wide-mouthed bottle. 

Roller bandages are made out of corrosive-sublimate 
gauze. 




Fig. 2. — The author's 
iodoform duster, with 
screw cap and removable 
bottom lor re 



replenishing. 



Note. — Koller bandages made of a starched fabric known as 
" crinoline," or " crown-lining," are very useful in completing every 
dressing. They are moistened in water, and applied over the dry 
roller-bandage. They soon become stiff again, and make a very compact and neat dressing, 
that will not shift easily. The stuff is the same that is used extensively for plaster-of-Paris 
bandages. 



In emergencies various substances of absorbent qualities can be utilized 
as dressings ; such are, for instance, cotton, moss, and sawdust. 

b. Absorbent cotton, or common cotton batting, well soaked in 
corrosive-sublimate solution, then wrung out, will make a tolerable dress- 
ing. Its drawbacks are that it packs and gets hard and lumpy, but, prop- 
erly used, it will answer every practical purpose. Care should be taken 
not to tear the cotton into irregular masses. After unrolling it, suitably 
large, square pieces should be cut off with the scissors ; these pieces should 
be folded, then soaked in the lotion, squeezed out hard, and unfolded again, 



16 EULES OF ASEPTIC AND ANTISEPTIC SURGEKY. 

thus preserving their shape and uniform thickness. Two or more of these 
pieces laid one oyer another will make a very passable dressing. 

Case. — Michael B., aged sixty-three, sustained, early in the morning of November 
13, 1883, a compound fracture of the left elbow-joint. He was put to bed, and, under 
the advice of the family attendant, applications of cold water were made to the injured 
part. Twelve hours after the injury, the author found a Y-shaped fracture of the lower 
end of the humerus, the conical sharp point of the upper fragment protruding through 
a small wound above the olecranon. The joint was filled with a large clot, and some 
oozing from the perforation was noticed. The edges of the perforation wound were 
snugly fitting around the protruding bone, and during the subsequent manipulations 
good care was taken not to allow the bone to slip back. Not having been informed 
of the nature of the injury, the author arrived unprepared at the patient's bedside. The 
case, however, did not brook delay, hence everything had to be extemporized. Sev- 
eral ounces of a ten-per-cent alcoholic solution of corrosive sublimate and a little iodo- 
form were ordered from the nearest druggist, and at the same time several bundles ot 
common cotton batting were procured. Soon plenty of a 1 : 1,000 corrosive-sublimate 
solution was ready, in which square pieces of cotton were soaked as described. The 
patient's poverty compelled an economical management of affairs. An old but clean 
bed-sheet was ripped up into roller-bandages, which were likewise impregnated. This 
done, soap and hot water were applied to the elbow, and the skin was shaved clean all 
around, but especially near the perforation. This was followed by a vigorous rubbing 
off of the skin and protruding bone with the mercuric lotion, which at the same time 
was copiously poured over the region of the elbow from a pitcher. After this, reduction 
of the protruding bone and adjustment of the fragments by extension of the arm was 
effected. The size of the perforation -hole at once became much smaller. In order to 
provide some drainage, a small fillet of cotton, well dusted with iodoform, was inserted 
into the cutaneous part of the outer wound, which was also liberally dusted. Over 
this were placed four layers of cotton pads, which were snugly bandaged to the limb. 
Two lateral splints, made of a pasteboard box, secured the extended position, in which 
the arm was suspended from a nail in the ceiling. The temperature never rose above 
100° Fahr. Nov. 19. — The dressings were removed. The swelling, due to the effusion 
of blood, had disappeared to a great extent. Oozing had ceased; no suppuration. 
The fillet of cotton was withdrawn, and the arm was put up in a pi aster-of -Paris splint 
flexed at a right angle. Passive motion was commenced on removal of the splint, four 
weeks after the injury. Ultimate result was ascertained in October, 1884: Flexion 
was normal; extension could not be carried beyond 140°. 

Co Sawdust. — With a view to the occasional impossibility of procuring 
any of the common dressing materials in times of war or some other public 
calamity, the author has tested the efficacy of sawdust as a dressing during 
his service at Mount Sinai Hospital, extending from August 1, 1883, till 
February 1, 1884. Clean pine, spruce, or hemlock sawdust was impreg- 
nated with a 1 : 1,000 solution of corrosive sublimate for twenty-four hours ; 
then it was spread on sheets of muslin to dry, and finally was inclosed in 
different-sized bags made of cheese-cloth gauze. To prevent the shifting of 
the sawdust, a thin layer of wood-shavings, called by the trade "excelsior," 
was first inserted into the open bag ; then a proportionate quantity of saw- 
dust was evenly strewed into the meshes of the "excelsior," and then the 
bag was closed by stitches made with threads soaked in mercuric lotion. 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 17 

The thickness of the bags varied, according to their size, from one to two 
inches. After the wound was drained and sewed, some iodoform gauze 
was placed next to it ; then came one, two, or more smaller bags, and on 
top a large bag, the whole being snugly fastened with roller bandages. 

Aside from the trouble of preparing the bags, they were found very con- 
venient in applying and quite efficient in absorbing blood and serum, and 
preventing decomposition. 

d. Moss. — The different species of sphagnum, coating the surface of peat- 
bogs and the trunks of dead trees in our northern forests, are excellent 
material for making dressing-bags. On account of its cheapness, small 
weight, elasticity, and great absorbing power, moss has displaced other 
dressings at almost all of the surgical clinics of Germany. Its preparation 
is very simple. It has to be gathered with some care — that is, with no ad- 
mixture of the soil. After being dried, it is impregnated with corrosive 
sublimate, inclosed in gauze bags, and is ready for use. Moss-bags are in 
daily use at the German Hospital since 1884, and can not be praised enough 
both for their handiness and effectiveness. But, like other similar dress- 
ings, they are not adapted to the needs of the general practitioner, and will 
find their principal employment in hosjDital practice. 



in. PRACTICAL APPLICATION OF RULES. 

1. In operating. — In order to gain a coherent idea of the practical work- 
ings of the aseptic apparatus, we shall now rehearse all the steps of a well- 
conducted operation. 

Assuming that a cancerous breast is to be removed in the rooms of the 
patient, it is first necessary to select a suitable person to act as nurse. Her 
duty is to administer a laxative the day before the operation, and to care- 
fully scrub with soap and brush the patient's breast, corresponding shoulder, 
and axillary space x»n the day preceding and on the day of the operation. 
A clean, well-lighted room is selected, out of which all unnecessary furniture, 
hangings, etc., should be removed. A bare, well-scrubbed floor is prefera- 
ble to a carpet. One or two narrow kitchen-tables, covered with a quilt 
and provided with a straw pillow, will make a capital operating-table. A 
piece of rubber cloth (3x-± feet) is placed over the quilt, and a clean sheet 
is laid on top. The nurse provides soap, nail-brush, plenty of hot and cold 
water, and towels. The operator and his assistants arrive at least a half- 
hour before the appointed time of the operation. Everybody's hands are 
washed in hot water with soap and brush. The necessaries are now un- 
packed and arranged, and the solutions of carbolic acid and corrosive sub- 
limate are mixed, for which purpose six or eight well-cleansed quart bottles 
should be held in readiness by the nurse. A fountain syringe is filled with 
sublimate solution, and suitably suspended from a nail or chandelier near 
the operating-table. A new pail or bucket is filled with hot water for rins- 
ing the blood out of the sponges ; alongside of it is placed a basin filled with 



18 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

a three-per-cent solution of carbolic acid for the reception of the cleaned 
sponges, from which they ought to be handed to the assistants by the nurse. 
Two more tin basins are filled with a corrosive-sublimate solution, and 
placed on chairs to the right and left of the operating-table for the occa- 
sional rinsing of the hands of the operator and assistants. The instruments 
are arranged on an adjacent table in a certain order, which, to prevent 
confusion and ill-temper, should be rigidly adhered to during the entire 
operation. 

Note. — The author has found that it is very convenient to be independent of the patient's 
resources, as far as the necessary vessels for sponges and instruments are concerned. A nest 
of four good-sized, flat-bottomed block-tin wash-basins, six tin soup-basins (six inches diameter), 
and four tin bake-pans, will serve every purpose, and the small expense will be abundantly 
repaid by the cleanliness and sense of comfort that will result. This small inventory will keep 
long, and may serve again and again at many operations. 

All vessels are wiped clean. The knives, sharp and blunt retractors, 
scissors, anatomical, mouse-tooth, and dressing forceps, probes, and grooved 
director should be put^into one pan with carbolic lotion ; all the artery for- 
ceps by themselves into another one. Between the two pans is placed a 
third one, filled with hot water, in which all the instruments not in actual 
use should be rinsed free from blood before being returned to the carbolic 
lotion. This will keep them and the carbolic lotion clean and bright all 
the while, and no time will be lost in hunting for them in the bottom of a 
turbid pool of soiled carbolic solution. In a smaller tin basin, ligatures, in 
another one needles, are arranged, threaded with fine (No. 0) and coarser 
(No. 1 or 2) catgut. A third small basin will hold the drainage-tubes and 
a number of safety-pins. 

The dressings are now attended to. Eight or ten small (6x8 inches), and 
just as many large (19x28 inches), compresses of gauze are cut, care being 
taken not to make the dressings too scanty, as an ample first dressing may 
save the trouble of many subsequent dressings. The best rule is to let the 
outermost compresses overlap the wound on all sides by at least eight inches. 
To this should be added a sufficient number of strips of iodoformed gauze, 
three or four rather wide gauze roller-bandages, and the same number of 
starched or crinoline roller-bandages. All this should be wrapped in a 
clean towel and laid aside in a secure place until needed. 

All this having been attended to, anaesthesia may commence in an adja- 
cent room. The anaesthetizer should be provided with ether and a cone, a 
tin basin for the reception of ejecta in case of vomiting, a towel, a hypo- 
dermic syringe, a wide-mouthed bottle with morphine solution for injections 
in case anaesthesia be imperfect, a similar bottle with whisky to be used in 
case of heart-failure ; finally, with a dressing-forceps and gag for withdraw- 
ing the tongue if it should sink back on the epiglottis. 

The anaesthetized patient is placed on the operating-table, and the parts, 
being exposed, are freely soaped and shaved. After this a piece of rubber 
cloth (3x4 feet) is so placed over the patient's body as to leave exposed 
only the field of operation. Now the parts are well rubbed off with a towel 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 



19 



dipped in corrosive-sublimate solution and freely irrigated, and a number 
of clean towels wrung out of the same solution are suitably spread around 
the field of operation, protecting the operator and assistants against contact 
with the clothing or body of the patient, and providing for a clean place 
where instruments or sponges may be laid down for a moment if necessary. 
The end of a wet towel is tucked under the breast and armpit of the side 
to be operated on, and is hung over the edge of the table in such a manner 
as to conduct the Wood and irrigating fluid into a bucket placed on the floor 
underneath. It serves as a drip-cloth. Every assistant should strictly attend 
to the duty allotted to him, and not meddle. All unnecessary talk should 
cease, and the work proceed in an orderly manner. The first assistant 
should keep his eyes open, and know and aid the operator's intentions. He 
should be alert, but not over-zealous. 




Patieat made ready for amputation of mainmi 



The anaesthetizer must take good care that, in case of vomiting, no ejecta 
are thrown on the wound or its vicinity. Towels soiled by vomit should 
be at once replaced by clean ones. 

Now the parts are distributed. The trustiest man serves as first assist- 
ant over against the operator ; a younger physician at the left of the operator 
is second assistant, and irrigates or helps as need may require ; another 
physician takes charge of the instruments and ligatures, and the nurse 
attends to the sponges, and keeps in readiness " sublimated " and dry towels 
and a pitcherful of corrosive-sublimate solution. 

Aprons are donned, everybody's hands are finally scrubbed with soap 
and brush, rinsed in mercuric solution, and the operation begins. 



20 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Note. — The employment of copious irrigation during operations requires measures for pro- 
tecting the person and clothing of the surgeon against the influence of the chemicals commonly 
used. An ample apron, made of light rubber sheeting, and reaching from the chin to the toes, 
is most convenient, and can be easily cleaned. The surgeon's shoes may be protected by a pair 
of light rubbers. However, they are apt to sweat the feet. The author overcame this draw- 
back by the use, at the hospital, of wooden pattens (French sabots) worn over the shoes. They 
are donned and doffed without the aid of the hands, and keep the feet warm and dry, and can 
be bought at 75 Essex Street, New York. 

In removing the breast and contents of the axilla, haemorrhage should 
be carefully attended to by ligaturing every bleeding vessel with catgut. 
Having removed the diseased parts, the wound is carefully irrigated, each 
recess being attended to in succession ; drainage and sutures are applied. 
The projecting end of the drainage-tube cut off "flush " is transfixed with 
a safety-pin, the wound is once more irrigated through the tube so as to 
clear it of clots, and the clots and irrigating fluid are removed from the 
wound by gentle pressure exerted with a sponge or two. Iodoformed gauze 
strips are next placed along the suture and around the drainage-tube, pass- 
ing under the safety-pin, and a few pads of gauze are held pressed against 
the wound while the patient is slightly raised to cleanse her back and face 
and the table from blood. The soiled towels are replaced by dry ones, and 
the dressing completed by applying as many gauze compresses as required. 
These are fastened rather tightly with gauze bandages, the other breast and 
arm-pits being first padded with absorbent cotton. A large, square piece of 
absorbent cotton, somewhat overlapping the dressings, is next applied, and 
snugly held down by crinoline roller-bandages ; the corresponding arm is 
included by the bandage or is placed in a sling ; the patient is brought to 
bed, and an opiate is administered. 

2. Change of Dressings. — In most cases where the rules above given 
are conscientiously and intelligently observed, no fever will follow the 
operation. After the effects of the anaesthesia are over, the patients will 
be found cheerful and contented, feeling no pain or sickness, their only com- 
plaint being the tightness of the bandage, which they will soon learn to 
bear. The temperature will range during the first three days at about 100° 
Fahr. ; after that it will sink to the normal standard. Sometimes, especially 
if the drainage is not properly placed, and some serum or a blood -clot is 
retained in the wound, the thermometer will indicate from 100° to 103° 
Fahr. As long, however, as the patient is cheerful, and does not feel sick 
with headache and general dejection, as there is no sharp, throbbing pain 
about the wound, or some other grave disturbance of the local or general 
comfort, no alarm need be felt. In these cases we have to deal with an ele- 
vation of temperature benign in character, and identical with the harmless 
fever observed after almost every simple fracture. It is due to the absorption 
of the extravasated blood or lymph, bland and harmless on account of the 
absence of putrefactive changes. This is Volkmann's " aseptic fever." 

The temperature soon becomes lowered, appetite reappears, and the dress- 
ings need not be disturbed. 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 



21 



Should, on the other hand, the patient complain of chilliness, headache,, 
sickness, general dejection, and drawing pains in the limbs, or persistent 
and increasing pain about the wound, the thermometer indicating at the 
same time a high or only a moderate elevation, the dressings should at once 
be removed, and a search instituted for the cause of the disturbance. 

Previous to this a new dressing should * be prepared similar to the one 
to be removed. This and a tin pan containing carbolic lotion, with a dress- 
ing-forceps, anatomical forceps, scissors, scalpel, grooved director, and a 
piece of drainage-tube, together with another vessel holding a few small 
pads of cotton wrung out of the same solution, should be placed on a small 
table near the bed. An irrigator filled with warm carbolic or mercuric 
lotion should be suspended from the bedpost or a nail, and a pail for the 




Fig. 4. — Change of dressings after amputation of the thigh. 

reception of the soiled dressings should be at hand. A piece of rubber cloth 
covered with a draw-sheet and spread under the patient's back will protect 
the bed, and a pus-basin or square tin pan held alongside of the patient's 
thorax will receive the irrigating fluid. 

After this the turns of the roller-bandage are cut through without jar, 
and the outer layers of the dressing are gradually removed. As the deeper 
parts are being raised, irrigation should commence, in order to moisten the 
gauze and aid in its gentle removal. Care should be taken not to disturb 
the drainage-tubes. After the removal of the soiled dressings, the physi- 
cian's hands should he carefully cleansed before touching any part of the 
wound. While the irrigating stream is playing, the vicinity of the wound 
is gently wiped with a small pad of moistened cotton, in order to remove 
clots of blood or fibrin that can not be dislodged by irrigation. 



22 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

If the edges and vicinity of the wound look normal, the skin pale, not 
swollen, and not painful to touch, it should be forthwith redressed. A care- 
ful physical examination of the internal organs will then certainly reveal, 
as the cause of the fever, some internal complication, as, for instance, pneu- 
monia, or, at any rate, some newly developed or overlooked disorder inde- 
pendent of the wound. 

If the aseptic measures employed were insufficient, the edges of the 
wound will be found swollen, reddened, and painful ; the wound will have 
lost its aseptic character, and is the seat of a septic process ending in sup- 
puration. Prompt action is required to limit the inevitable destruction of 
tissue, and to check the further poisoning of the system. 

From this moment on, aseptics must give way to antiseptics ; prevention 
having failed, curative measures must step in to eliminate the mischief 
that might have been prevented by the exhibition of more care, attention, 
or skill. 

The therapy of septically infected or suppurating wounds will be treated 
in the following chapter. 

In case that the course of the healing of the wound is correct, as indi- 
cated by the absence of local or general disturbance, the first dressing may 
remain unchanged for from seven to forty days. Flesh-wounds should be 
dressed on the seventh day, as it is desirable to remove the drainage-tubes 
and sometimes the stitches. The finer catgut sutures will generally be 
absorbed by this time, and their exposed part can be simply wiped away. 
Where stout retention sutures were employed for the approach of the edges 
of a wide, gaping wound, they will be found cutting through the tissues 
by this time, and quite useless. They should be removed, and the stitch- 
holes dusted with iodoform. According to the completeness of the result, 
the dressings will have to be changed every third, fifth, or seventh day, 
their bulk decreasing with the diminution of the secretions. Finally, the 
few granulating spots need only a dressing consisting of a patch of some 
unirritant plaster, such as empl. cerussae or empl. hydrarg., and an occasional 
touching with nitrate of silver, to aid final cicatrization. Where the opera- 
tion has involved parts of the skeleton, as in amputations of extremities, 
exsections of joints, necrotomies, etc., the dressings have to be left undis- 
turbed much longer. After exsections of the knee-joint, for instance, where 
bony ankylosis is aimed at, the first dressing is not removed without a clear 
indication before the thirtieth or fortieth day. No patient should be dis- 
charged u cured " before cicatrization is complete, as it has happened that 
such "cured" cases, left to their own care, contracted erysipelas the day 
after their discharge, and died of it. 

Note. — All the manipulations about a freshly agglutinated wound should be very deliber- 
ate and gentle. In removing stitches, a forceps should gently raise the thread ; then it should 
be cut as close to the stitch-hole as possible, and lightly withdrawn. Drainage-tubes are 
grasped at the projecting end, gently rotated to and fro till they are freely movable, then with- 
drawn. Sometimes it will be found that a painless fluctuating swelling occupies some deeper 
part of the wound. In these cases retention of serum is generally caused by clogging of the 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 23 

•drainage-tube by a clot. On withdrawing the tube, a quantity of clear or turbid yellowish serum 
will escape. In these cases it is good to replace the cleared tubing to prevent further retention, 
and thus to bring about contact of the separated walls of the wound, which will at once become 
adherent. At the subsequent change of dressings, the tube can be definitively removed. 

Case. — Mrs. Clara G., aged forty-six. Alveolar glandular cancer of an aberrant 
{detached) lobe of the right breast. Tumor of the size of a small fist, situated in the 
axillary space close to the edge of the pectoralis major muscle. It was connected by 
a stout pedicle with the adjacent part of the breast-gland proper. Jan. 16, 1885. — 
Amputation of mamma; total evacuation of axillary fat and glands. Drainage by 
counter opening made through the latissimus dorsi muscle. Suture of the entire wound 
except a part of axilla, where the skin had been extensively removed. Course of heal- 
ing feverless. Change of dressings on the tenth day. Primary union of all the sutured 
parts. Axillary wound granulating. Under the lower flap of the breast-wound a pain- 
less, soft, fluctuating swelling discernible. By gently inserting a probe between the 
corresponding edges of the united wound, entrance into this sac was effected, where- 
upon about two ounces of a yellow, slightly turbid, and very viscid serum escaped. A 
small drainage-tube was inserted, and the wound was redressed. Jan. 30th. — Walls 
of the cavity were found firmly adherent. Tube removed. No suppuration. 

The interior of freshly healed wounds of normal appearance should never 
be syringed ; the injection of a strong jet of fluid is unnecessary and often 
injurious, as it tends to separate tender adhesions. 



IV. ASEPTIC MEASURES IN EMERGENCIES. 

Unremitting attention to, and a severe self-discipline in always carrying 
out the measures of strict cleanliness known to be necessary to uniform 
success in the management of wounds will gradually become, however 
irksome in the beginning, a mere matter of accustomed routine. As the 
mind and senses learn to exercise vigilance without special effort, the sur- 
geon's results will become more and more gratifying. His attention, freed 
from the severe strain unavoidable in acquiring command of the detail of 
a difficult business, will concentrate itself upon higher objects, and the 
smooth routine resulting from long and severe training will not divert 
attention from the finer detail of his special work. 

It is a great mistake, paid for by the loss of limbs and lives, to belieA r e 
that the mastery of practical cleanliness or asepticism can be acquired with- 
out a clear comprehension of the principle, and without earnest and severe 
training in the handicraft of asepticism. The wholesome truth, that failure 
of achieving primary union in fresh wounds is mainly and almost always 
due to one's own lack of knowledge and skill, and that these attributes can 
be secured only by the exercise of great diligence and many, often unsuc- 
cessful trials, should be constantly present in our mind. Failures are bitter 
lessons, but their honest study will inevitably bring to light the causative 
deficiencies, and will teach us to avoid them. 

The school for learning to employ the principles of asepticism is open 
to every general practitioner in the treatment of the many affections and 
injuries pertaining to minor surgery. Mistakes made in the removal of a 



24 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

wen or the treatment of an incised wound of the hand are easily found out 
and easily corrected. They carry much and sometimes more instruction 
than a large operation. It is wicked to attempt to learn the first lessons of 
aseptic surgery in laparotomy, when, possibly, the surgeon's experience is 
bought with the life of his trusting patient. The attempt of removing an 
ovarian tumor, for instance, should be permitted only to those who have 
learned to invariably heal a fresh wound by primary adhesion, as this is the 
first and sole test of the possession of the ability justifying such a grave 
undertaking. 

Emergencies will necessarily involve varying modifications of the means, 
never a deviation from the principle of asepticism. 

A hasty tracheotomy for the removal of a foreign body, a herniotomy 
to be done in the dead of night amid the squalid surroundings of a tene- 
ment, or the first care of a compound fracture or a gunshot-wound, will 
present special and varying difficulties, to be overcome only by good train- 
ing, circumspection, and versatility. They can be overcome, as many 
examples in the experience of every successful surgeon testify. 

In addition to the case of compound fracture of the elbow-joint quoted on 
page 14, another instructive case may be told from the author's experience. 

Case. — Herman John, laborer, aged sixty-one. Eight, irreducible, strangulated 
femoral hernia. Kupture of long standing, strangulated since the evening of April I, 
1882. Symptoms of great acuity necessitated prompt action. Dr. H. Wettengel, the 
family attendant, administered the anaesthetic in the middle of the afternoon of the 
following day, while author was making the necessary preparations for the presuma- 
bly inevitable operation. The place was a narrow, dark, rear room of a rear house of 
a squalid tenement, and a lamp had to be procured. The divested patient's pubic and 
inguinal region was shaved, while anaesthesia progressed. A flat bake-pan was covered 
with one of the few clean towels to be had; on this were spread the instruments, and 
over them was poured a quantity of a five-per-cent carbolic lotion. No sponges were 
on hand, as the summons had been very hasty, and no time was afforded for prepara- 
tions. Therefore, a part of a clean bed-sheet was torn into a number of small pads, 
which were well soaked in the same lotion to serve as sponges. A remnant of the 
lotion was saved in a pitcher for purposes of irrigation. After an unsuccessful attempt 
at reposition, the inguinal region and the surgeon's hands were once more well soaped 
and washed off with the carbolic lotion. The epigastric artery had to be tied, and ex- 
ternal herniotomy was performed. A small knuckle of gut slipped back easily into the 
abdominal cavity, but evidently did not represent all the contents of the sac, within 
which an additional soft body could be felt that resisted every gentle effort at reposi- 
tion. The sac being opened, a slender portion of omentum was found to be adherent 
to it. This, being dissected away, was replaced into the abdominal cavity. The outer 
wound was well irrigated, and united by a number of catgut sutures. A few strands 
of catgut were inserted into the lower angle of the wound for drainage. In the ab- 
sence of other dressings, a clean sheet was used for the manufacture of a number of 
compresses and roller-bandages. These, being well soaked in carbolic lotion, were 
applied to the wound in the shape of a spica bandage. Vomiting ceased. Oozing 
being very scanty, the dressings soon became dry, and, the patient's condition being 
excellent in every respect, they were not disturbed until a fortnight after the opera- 
tion, when the wound was found healed throughout by the first intention. 



ASEPTIC WOUNDS— ASEPTIC TREATMENT. 



25 



Yet it must be said that such conditions render operating very risky, 
and in every way uncomfortable. If unavoidable, the additional risk must 
be shouldered by the patient as well as the surgeon. 

Operating Bag and Kit- 
Timely preparation made in 
the shape of procuring a well- 



arranged 



hand-bag, contain- 




ing the most necessary arti- 
cles for operating in an emer- 
gency, will well repay the 
small expense and trouble. 

A leather hand-bag, about 
sixteen inches long, will be 
sufficiently large. 

Have a sufficiently long, 
rather stout strap sewed to 
one side of the interior of the 
bag, so as to provide loops for five or six bottles, which will be held safely 
in the upright position. The first loop will be occupied by a half-pound 
tin can of ether ; the second is allotted to a two-ounce bottle of corrosive- 
sublimate solution (ten per cent alcoholic) ; the third to a four-ounce bottle 
of pure carbolic acid : the fourth to a wide-mouthed bottle containing cat- 
gut and silk of different sizes on spools ; the fifth to a wide-mouthed bot- 



Fig. 5. 



-Author's operating bag, with tin pans and 
rubber cloths strapped to it. 




enor ot operating 



tie filled with drainage-tubes of different sizes in carbolic lotion ; the sixth 
to a wide-mouthed fruit-jar with tight cap, containing two or three dozen 
sponges in carbolic lotion. A stout pair of scissors for cutting the dress- 



26 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



ings, a dressing-forceps for the arises thetizer, and a razor can be conveniently 
stuck in behind the bottles. On the other side of the bag two more spaces 
are reserved for a dusting-box rilled with iodoform-powder and a wide- 
mouthed vial for an assortment of surgeon's needles. The bottles contain- 
ing pure carbolic-acid and corrosive-sublimate solution should be inclosed 





Fig. 7. — German instrument-pouch. 



Fig. 8. — Interior of German instrument-pouch. 



in boxwood or tin cases for safety. A side-flap will hold nail-brush, safety- 
pins, and one complete dressing rolled up in a clean towel. The body of 
the bag is reserved for the instruments, which are rolled up in another clean 
towel, and for three or four small tin basins, together with a fountain syringe 
and ether cone, each kept in a separate rubber sponge-bag. 

To the bottom of the hand-bag is strapped on the outside a nest of four 
oblong tin pans of fitting size. 

Such a bag contains all the necessaries for an emergency, and has been 
used by the author seven years with much satisfaction. 

Note. — Surgical pocket-cases, as generally sold by surgical cutlers, are mostly incomplete 
and unsatisfactory. Their main objection is the small size and frailty of the instruments con- 
tained in them. The instrument-pouch depicted in Figs. 7 and 8 is very complete, and is worn 
strapped to the waist underneath the coat. It contains, besides the instruments held by a com- 
plete pocket-case, a sharp spoon, a key-hole saw, a flat oblong iodoform dusting-box of hard 
rubber, and a set of diverse detachable knife-blades, that can be fitted to smooth hard-rubber 
handles, all very easy to clean. In an emergency, the hip-pouch will be found large enough for 
the reception of one complete dressing to a moderate-sized wound. 



SOILED WOUNDS— ANTISEPTIC TREATMENT. 27 



CHAPTER III. 

SOILED WOUNDS— ANTISEPTIC TREATMENT— DIFFERENCE BETWEEN 
ASEPTIC AND ANTISEPTIC METHODS.— ILLUSTRATION OF ANTI- 
SEPTIC METHOD. 

Is the preceding chapter the treatment of freshly made, clean, or un- 
contaminated wounds was discussed ; its subject was the aseptic form of 
treatment — that is, the manner in which a fresh or clean wound has to be 
managed in order to prevent its septic infection. 

The aseptic discipline is a purely preventive one. 

Antiseptic treatment, on the other hand, refers to such wounds as have 
become the seat of infection, causing inflammation, suppuration, or the 
higher forms of sepsis — phlegmon and gangrene. The object of the anti- 
septic treatment is the limiting and elimination of established septic pro- 
cesses by drainage and disinfection. It is also preventive, but in a narrower 
sense than the aseptic method. There all mischief is prevented from the 
outset ; here further extension of present mischief is sought to be checked. 
The aseptic method will generally preserve all the parts involved ; the anti- 
septic method can not restore the integrity of parts destroyed by ulceration, 
suppuration, or gangrene. 

Illustration of Antiseptic Method. — For the sake of illustration, let us 
go back now to our former example of breast-amputation. 

Some gross fault having been committed, such as, for instance, the use 
of unclean instruments, or a sponge that, having fallen to the floor, Avas 
picked up by the nurse and was handed for use in the wound. The mild 
course of the case is compromised, and trouble will follow. 

In such cases the patient's general condition is deeply disturbed, more 
or less high fever-is present, with headache, sickness, general dejection, and 
drawing pains in the limbs. The tongue is foul, much thirst and loss of 
appetite are complained of. The wound is painful and throbbing, and the 
patient dreads any movement lest the sore parts be hurt. 

Under these circumstances an immediate examination of the wound is 
imperative. The preparation mentioned in the preceding chapter being 
made, the wound is exposed. Its edges and the vicinity will be found angry- 
looking, swollen, hot, and tender. 

The stitches should be all removed. The point of the grooved director 
should be inserted between the edges of the wound, which are gradually 
separated till the index-finger can be insinuated. Exerting gentle pressure, 
the wound is thus opened throughout its entire extent. One or more small 
foci containing pus will be laid open and discharged. The wound should 
be carefully irrigated with warm mercuric lotion till the slight haemorrhage 
ceases, and lightly filled with sublimated gauze. After this the outer dress- 
ings, with the addition of an externally placed piece of rubber tissue to pre- 



28 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

yent evaporation, should be renewed, and the timely interference will be 
soon rewarded by a decided improvement in the patient's condition. In 
these cases the dressings must be changed as often as they become soiled 
through. If the fever should continue, renewed search must be instituted 
for overlooked points of retention. 

In some cases examination of the wound will reveal only partial or quite 
circumscribed inflammation. In locating the exact point of retention, the 
sensations of an intelligent patient will greatly aid the surgeon. If the 
retention be near the edges of the wound, the grooved director will easily 
separate them and find its way into the focus. A dressing-forceps should 
be then insinuated along the director, and withdrawn with its branches 
partly opened. Pus escaping, a slender drainage-tube should be inserted 
into the track. 

If the point of retention be remote from the edges of the wound, 
and its locality well marked by redness and pain, an incision will best 
answer the purpose, and often may prevent suppuration of the rest of 
the wound. 

Let us assume that for one reason or another nothing efficient was done 
to relieve the patient on the second or third day after the operation. Finally, 
the increasing severity of the symptoms will compel some action, and, the 
wound being laid bare, the following state will be generally met with : The 
wound will be more or less gaping, ichor or pus escaping everywhere ; the 
skin will appear flushed, swollen, and painful ; the edges of the wound will be 
marked by a grayish-yellow, closely adherent coating, that extends through 
its whole interior. This coating represents molecular, often deep-going 
necrosis of the wound surface. Independent abscesses will often be found 
established along the connective-tissue planes contiguous with the wound, 
and should be forthwith incised and drained. The wound should be well 
irrigated and loosely filled with sublimated gauze. Over this should be 
applied a moist dressing of ample proportions, covered with an overlapping 
piece of rubber tissue to prevent evaporation and inspissation. The secre- 
tions will thus be readily and continuously drained away and disinfected, 
and the warm moisture of the dressings will at the same time exert a very 
soothing influence upon the inflamed parts. Frequent, at least daily, change 
of dressings is proper, accompanied by copious irrigation. Detached shreds 
of necrosed tissue should be removed with thumb-forceps and scissors. If 
new abscesses form, they must be found and opened promptly. The fever 
will soon abate, and the wound will gradually assume a clean granulating- 
appearance. As the amount of secretion diminishes, the dressings should 
be changed less frequently. 

Essentially, the so-called "idiopathic " phlegmon, or spontaneous sup- 
puration (abscess) is a form of local septic infection which can be traced 
back to an infection extending from a lesion of the skin or the mucous 
membranes. 

Even the suppurative or infectious form of osteomyelitis must be classed 
under this heading. 



THE TREATMENT OF ACCIDENTAL WOUNDS. 29 

But, on account of the great practical importance of the subject, requir- 
ing special consideration of several anatomical regions involving important 
modifications of the antiseptic procedure, it is deemed expedient to treat 
of this theme in a special chapter. 



CHAPTER IV. 



SPECIAL RULES REGARDING THE TREATMENT OF ACCIDENTAL 

WOUNDS. 

I. TEMPORARY MEASURES. 

Taking charge of a fresh case of accidental wounding, the surgeon 
should bear in mind that, on the one hand, by the avoidance of suppura- 
tion, a complete or almost complete restitution of normal conditions can be 
accomplished in a great majority of cases ; on the other hand, suppuration 
will enormously increase the gravity of a given injury. A compound fract- 
ure of the leg, or an incised wound of the wrist, with opening of joints and 
severing of arteries, veins, and tendons, may serve as examples. 

In approaching a fresh case of bloody injury, we should always consider 
the possibility that the wound may be surgically clean, or may still be asep- 
tic, and that our first ministrations should not carry septic contamination 
into the wound, and thus harm the patient instead of aiding him. As a 
matter of fact, a large proportion of incised and lacerated wounds, of com- 
pound fractures by blunt force or gunshot, are aseptic. They need no dis- 
infection. The surgeon's first object should be in these cases not to spoil 
matters by hasty action and ill-considered zeal. With the comparatively 
rare exception of injuries to large vessels accompanied by dangerous haem- 
orrhage, where immediate action is imperative, conditions should be created 
by the surgeon, under which safe — that is, aseptic — approach to the wound 
is made possible. Temporary protection of the wound in the shape of a 
simple dressing is meant thereby. Iodoform-powder dusted profusely over 
the wound and its vicinity, a compress made of a clean towel dipped in hot 
water or carbolic lotion, also well dusted with iodoform and tied on to the 
wound, will be sufficient. The addition of a temporary splint in cases of 
compound or gunshot fracture will make transportation to the patient's 
home or to a hospital possible, and will thus afford time for the absolutely 
necessary preparations. Extensive or even superficial examination of an 
accidental wound by probing or digital exploration in the street, on a train, 
or in a railroad-station or drug-shop, is strongly to be condemned, as it 
almost necessarily exposes the wound to unavoidable infection. Meddle- 
some and untimely surgery of this kind smacks of ostentation, is unneces- 
sary, and in many cases positively more dangerous than the injury itself. 



30 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Bergmarm's experience during the Russo-Turkish war has shown that most 
gunshot wounds are aseptic, and that, with the exception of those cases 
where shreds of soiled clothing or gun-wads were carried along by the pro- 
jectile into the bottom of the wound, healing without suppuration can be 
confidently expected if the wound is not infected by meddlesome and un- 
cleanly surgery. These experiences refer principally to gunshot fractures 
of the knee-joint. 

As a matter of fact, it may be safely assumed that an examination by 
probing or digital exploration, performed on the filthy floor of a public 
place or on the street pavement, even by the most experienced surgeon, can 
not be, and is not cleanly or aseptic. It is extremely dangerous, unnecessary, 
hence culpable. Even in most cases of profuse arterial haemorrhage, mesial 
constriction with an extemporized tourniquet, as, for instance, the " Span- 
ish windlass," or digital compression of the afferent arterial trunk, can be 

successfully employed, while the patient 
is transferred into a suitable locality, 
where permanent relief can be safely af- 
forded by deligation. 

The collected and businesslike manner 
of the surgeon will at once allay confu- 
sion, prevent hasty and injurious interfer- 
ence, will infuse the patient and those 
present with hope and confidence, and 
will facilitate well- 
considered and ra- 
tional action. 

As a rule, the 
fate of a fresh 
wound is deter- 
mined by the views 
and training of the 
physician who first 
attends to it. If 
the patient be so 

fortunate as to fall in with a man fully imbued with the spirit, and familiar 
with the practice of aseptic surgery, he is truly to be congratulated, because 
his chances of avoiding suppuration are excellent. If his first attendant be 
one of the still numerous band, to whom wound infection by dust or filth 
adherent to hands or a probe be a myth, woe unto him ! Without previous 
cleansing, immediate probing of the gunshot wound of a vertebra, for 
instance, accompanied by digital exploration, will be performed on the 
patient extended on a mattress laid on the dirty floor of a railroad station. 

Of course, the bullet will not be found, and nothing beyond the infec- 
tion of the wound will be accomplished. A dressing will be applied any- 
way, and the patient will be taken home. Suppuration, that otherwise 
might have been avoided, will surely set in, and the patient is doomed. No 




Fig. 9. — Extemporized tourniquet — " Spanish windlass. 



THE TREATMENT OF ACCIDENTAL WOUNDS. 31 

amount of consulting can devise a way, for no surgical skill can establish 
efficient drainage of the inaccessible parts of the wound. The chances for 
recovery were thrown away here from the outset. 

On taking charge of a fresh wound, the fearful and often irremediable 
consequences of a first false step should Jbe always present to the mind of 
the surgeon, and his attention should be directed chiefly to the avoidance of 
septic infection. A temporary aseptic dressing having been applied, the 
general condition and comfort of the patient should be looked to by the 
administration of stimulants or sedatives. After transfer home or to a 
hospital, the necessary measures for permanent relief should be carried out 
as soon as the patient's general condition will permit. 

II. DEFINITIVE RELIEF. 

Preparations, comprehensive and thorough, as required for an aseptic 
operation, should now be made in the manner described in Chapter II. 

The patient is well stimulated if necessary, is anaesthetized if the case 
require it, and, his clothing being removed by cutting or in some other 
proper manner, he is placed on the operating table. 

After this should come a careful cleansing and sterilization of the sur- 
geon's and his assistant's hands by scrubbing with soap and brush and 
immersion in a germicide lotion, followed by a likewise thorough cleansing 
of the integument in the vicinity of the wound. Plenty of soap-lather, 
with the use of a razor, scrubbing with soap and brush, rubbing and wash- 
ing off with a solution of corrosive sublimate, will soon accomplish this. 

1. Contaminated Wounds. — The character of further procedures will have 
to be decided by the answer to the question : Is the wound clean or is it con- 
taminated^ Gross evidence of contamination, such as, for instance, street- 
dirt imbedded in the wound or the clots, or the knowledge that the wound- 
ing was done with a filthy instrument, as, for instance, a foul and fetid 
butcher's cleaver, "will answer the question in the affirmative. In these 
cases the leading object should be thorough cleansing and disinfection 
of the wound, followed by very comprehensive measures at drainage. If 
the external wound be small, it has to be well enlarged, so as to afford a 
good insight. Every nook and recess of the wound should be systematically 
gone through, cleansed of clots and dirt, thoroughly irrigated, and well 
drained. Great care must be taken not to overlook recesses, as one particle 
of filth left behind unawares, may cause very grave trouble. 

Drainage of the more remote recesses should be made as direct as possi- 
ble ; that is, a rubber tube carried to the surface from a distant corner of 
the wound through a properly placed counter-incision, will be more direct, 
therefore better, than a long tube bent or twisted and brought out through 
a distant opening. 

Haemorrhage must also be, of course, well stanched by ligature or 
otherwise. 

Divided tendons, nerves, muscles, or fractured bones are next united by 



32 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

suture, and, if the edges of the wound be viable, they are also approximated 
by sutures. Where extensive loss of substance precludes uniting of the 
edges, or where uncontrollable oozing prevails, the wound should be packed. 
This is best done by first lining the entire wound with one layer of iodo- 
form] zed gauze, within which is packed a suitable number of loose balls of 
sublimated gauze. After a final irrigation and clearing of the drainage- 
tubes, the wound and its vicinity are enveloped in a moist dressing that 
should be protected from evaporation by a large piece of rubber tissue or 
Mackintosh. In case of fracture, the limb is supported by a splint. 

On account of their frequency, and their gravity in case of suppuration, 
scalp-wounds and their treatment may receive special mention. 

Scalp-wounds have been held undeservedly in bad repute on account of 
their alleged tendency to suppurate. They heal as kindly as, and in fact, 
on account of their great vascular supply, heal better than, many other 
wounds, provided that they be first carefully cleansed, well drained before 
suturing, and sufficiently protected by a suitable dressing from subsequent 
contamination. 

In case of a greater denudation of the cranium, the loose scalp should 
be raised (after shaving and thorough cleansing of the skin), blood-clots 
should be turned out, and the wound well irrigated and rubbed out with 
corrosive-sublimate lotion. A bistoury is inserted into the deepest part of 
the recess formed by the flap, and thrust out through it. Into this opening 
a short piece of slender tubing is placed, after which the edges of the 
wound are brought together by an exact line of sutures. A dry dressing will 
be proper in these cases. 

If the steps described above are adequately taken, as a rule no septic 
fever and no destructive suppuration will follow an accidental injury ; 
though aseptic fever, due to absorption of non-decomposed secretions, may 
often enough be observed. 

Tissues or bone whose vitality was compromised by the crushing force 
causing the injury will be gradually detached. This will be accompanied 
by a rather scanty secretion of thinnish sero-pus, and very little fever, if 
any. 

Case. — P. S., aged thirty-six, was, January 26, 1886, run over by a heavily laden 
truck, and was at once brought to the German Hospital, where he was anaesthetized 
about two hours after the accident. Under strict precautions the wound was examined. 
A laceration of the integument in front of and corresponding to the middle of the left 
leg, four inches long, was found. Compound comminuted fracture of the tibia and fibula. 
The tibia was broken into' four, the fibula into at least three fragments. Severe 
haemorrhage from the torn tibialis antica artery had caused an enormous infiltration of 
the leg, which had attained double the size of its fellow, and was quite cold. 
Esmarch's bandage was applied, the external wound was enlarged to about eight inches, 
the massive clots, some containing particles of street dirt, were turned out of the 
muscular interstices, and from between the fragments one perfectly detached piece of 
the tibia was extracted. From the middle of the main cavity into which the frag- 
ments protruded, a counter-incision was made backward through the calf of the leg, 
into which a large-sized drainage-tube was placed. Three more counter-incisions, cor- 



THE TREATMENT OF ACCIDENTAL WOUNDS. 33 

responding to as many recesses, were made. The torn artery could not be found. A 
large moist dressing was applied, and the limb fixed between two well-padded lateral 
board splints, held together by a pure gum bandage. Moderate oozing soiled the 
dressings somewhat during the following night, wherefore the elastic bandage was 
removed in the morning, and the soiled parts of the underlying dressing were well 
dusted with iodoform. Another envelope of gauze was laid on top of the old dressings 
and the splints were replaced and fastened with muslin bandages. Jan. 31st. — The 
patient's temperature had not risen above 100° Fahr., he complained of very little pain, 
no haemorrhage had followed, the circulation of the limb was good, hence the dressings 
were not disturbed until this date. The wound was found to be in good condition ; 
some blood-clots were still adherent to the drainage-tubes. Wound was re-dressed and 
limb put up in a solid plaster-of-Paris splint. In the beginning the dressings were 
changed about weekly; from February 15th, every fortnight. March 3d. — After the 
exuberant granulations surrounding it had been scraped away, the entire belly of the 
tibialis anticus muscle was found to be of a grayish-yellow color and necrosed. It was 
not putrid, although a good deal of secretion was present. The wound was enlarged 
and the necrosed muscle was removed. Thereafter the secretion diminished materially, 
although five sequestra were consecutively removed. Consolidation was rather slow, 
but finally complete, so that the patient was able to walk without support in Octo- 
ber of the same year. Shortening about one inch. If left to themselves, deep-seated 
and extensive contaminated wounds, presenting a small external orifice, are, for obvi- 
ous reasons, most dangerous. Free exposure, thorough-going cleansing and disinfection, 
together with good drainage, are then imperative. 

2. Aseptic Wounds. — The nature of many wounds and their causation 
are such as to preclude the probability of contamination. Most gunshot 
wounds and many compound fractures belong to this class. In these cases 
interference should he very discreet. It should consist of thorough cleansing 
of the integument, ordinarily an aseptic dry dressing, or, in case of doubt, 
of superficial drainage and a moist dressing, together with reduction and 
support and retention hy splint where a fracture requires it. 

Case. — John D., aged thirty-two, December 4, 1885, sustained a compound com- 
minuted fracture of -the upper half of the tibia by a horse-kick. Dr. W. T. Kudlich, of 
Hoboken, saw him immediately after the accident, cut off the clothing, disinfected the 
vicinity of the small wound, and dressed it amply with iodoform gauze. A temporary 
splint was also applied, and probing or examination was thoughtfully refrained from. 
The patient was brought to his home, where, the next day, he was anaesthetized. The 
temporary splint and dressings were removed, the vicinity of the wound was carefully 
cleansed and disinfected, and, with the observance of all necessary cautelm, a thorough 
examination of the injury was instituted. A compound comminuted fracture was easily 
made out, and three loose fragments of bone were removed. The laceration of the 
soft parts and ecchymosis were found very moderate, and confined to the tissues an- 
terior to the tibia. A couple of short drainage-tubes were inserted into two recesses, 
and, the wound being well irrigated, was enveloped in a moist dressing. The limb 
was put up in a solid plaster-of-Paris splint, with the knee bent at an obtuse angle, 
and was suspended from a frame. 

The temperature remained normal or almost normal throughout. 

Dec. 18th. — Appearance of wound normal. Moderate secretion due to limited 
necrosis of a loose fragment of bone. Dec. 28th. — Second change of dressings. Ex- 
uberant granulations have filled up the defect. Jan. 18th, — A fenestrated silicate-of- 



34 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

soda splint was applied. The secretion continued to be scanty. In May consolidation 
was perfect, but a small sinus remained until October, when, after the extraction of 
several small spicula of bone, definitive healing of the wound ensued. No appreciable 
shortening resulted. 

Note. — In the more extensive injuries of the extremities caused by crushing force, the 
gravity of the case hinges more upon the extent of the injury to the soft parts than to the bones. 
A compound fracture by direct force — for instance, the blow of a hammer upon the tibia, where 
the crushing and laceration of the soft parts are comparatively limited — is by far not as dangerous 
as, for instance, the stripping off of the entire integument of the lower extremity, or the crush- 
ing and pulpification of the large muscles, vessels, and nerves situated on the anterior and 
internal aspect of the thigh, though these latter injuries be uncomplicated with fracture. The 
shock and the presence of extensive thrombosis, in addition to the fact that, with the large quan- 
tity of mortified tissues, preservation of the aseptic state is extremely uncertain and difficult, 
class these injuries among the most grave and dangerous. 

3. Gunshot Wounds. — The fact that most fresh gunshot wounds are asep- 
tic has been pointed out by Esmarch, and is now well established. Reyher 
and Bergmann's experiences in the Russo-Turkish war put the fact beyond 
controversy. 

Wise precaution against infecting a fresh gunshot wound will be richly 
rewarded by excellent results. In most cases cleansing and disinfection of 
the skin in the vicinity of the points of entrance and exit, together with a 
dry dressing, will be sufficient. If the case is complicated by fracture, a 
suitable splint, preferably plaster of Paris (Bergmann), should be added. 

If the course is free from septic fever and suppuration, this will be mani- 
fest within the first three or four days ; in that case, the first dressing and 
the splint can be left undisturbed for the length of time required for the 
accomplishment of bony union. 

Flesh-wounds will be healed within a fortnight or three weeks. Gun- 
shot fractures will require a longer time for healing and consolidation, but 
are in no way different from ordinary compound fractures. 

The projectile will cause very little or no irritation in aseptic — that is, 
non-suppurating — gunshot wounds. Generally it will become encysted. 
Search for the projectile in the bottom of the wound is rarely indicated. 
It can occur, however, that pressure of a projectile or its fragment, or a 
sharp spiculum of bone on a nerve-trunk, may necessitate search and extrac- 
tion. This must be done under careful asepsis. 

It is even not necessary to remove a projectile lodged under the skin. 
It will do no harm if left there until the channel which it cut by its passage 
through the tissues is obliterated, when its removal by incision can not lead 
to an infection of the bullet-track. 

In cases of injury to large vessels or the intestines, immediate interfer- 
ence can not be delayed, but should be carried out under most rigid anti- 
septic precautions. 

Note. — Recent successes (W. T. Bull) achieved by immediate laparotomy and suture of the 
wounded intestines justify the procedure. 

Where the nature of the charge or the short distance from which the 
shot was delivered makes the entrance of a gun-wad probable, or where the 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 35 

examination of the superjacent clothing shows a large defect, rendering the 
probability great that shreds of soiled cloth have been carried to the bottom 
of the wound, dilatation, search, and extraction may be indicated. But it 
is better to wait in cases of doubt, as even these foreign substances may 
become encysted and harmless. 

Should suppuration follow, the patient will not be worse off than if a 
fruitless search had been made at the outset, and the use of the suppurating 
track as a guide will materially facilitate the finding of the irritating body. 

Note. — Reyher's observations (Volkmann's " Sammlung," Xos. 142, 143, 1878) may serve as 
a fair sample of the radical change that has taken place in the results of the treatment of gun- 
shot fractures. 

Gunshot fracture of the knee-joint was formerly considered an indication for immediate 
amputation. Reyher treated eighteen fresh cases aseptically — that is, by simply cleansing and 
disinfecting the skin about the wound, and occluding the same by an antiseptic dressing. Where 
the wound was gaping, or where there was ground to suspect the entrance of dirt or shreds of 
clothing into the bullet-track, dilatation, irrigation, and extraction of the foreign body, with sub- 
sequent drainage, was practiced before the wound was sealed up. Of these eighteen cases, fif- 
teen recovered, with movable knee-joints — 83 - 3 per cent of recoveries. One patient died of 
fatty embolism in twenty-four hours after the injury ; another of haemorrhage from the divided 
popliteal artery and vein on the fifth day ; and the third one of pyaemia. 

Of nineteen that came under his care several days after the reception of the injury, with 
well-established suppuration, eighteen died, and one recovered with a stiff joint. In spite of an 
energetic antiseptic treatment by incisions, drainage, and irrigation, a mortality of 85 per cent 
was noted. 

Of twenty-three that were not subjected to any form of antiseptic treatment, twenty-two 
died, one survived, a mortality of 95 - 6 per cent — clearly justifying the practice of the older sur- 
geons, who at once performed amputation in cases of gunshot fracture of the knee-joint. 

Infected accidental wounds or gunshot injuries that become the seat of 
suppuration can be classed under the heading of phlegmonous processes, and 
their treatment will be dealt with in a subsequent chapter. 



CHAPTER V. 

SPECIAL APPLICATION OF THE ASEPTIC METHOD. 

A. General Principles. 

I. TECHNIQUE OF SURGICAL DISSECTION. 

Modern surgery demands that the invasion of the uninflamed tissues 
of the human body by the surgeon's knife should be surrounded by all the 
safeguards that are known to be effective in preventing suppuration. The 
mortality following operations sanctioned by pre-antiseptic surgery has been 
remarkably depressed by a conscientious and intelligent adherence to the 
principles of surgical cleanliness. A large number of recently devised use- 
ful operations have become legitimate under the assumption that suppura- 



36 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



tion can be excluded. The large joints, the tendinous sheaths, and the 
peritoneal cavity are now safely accessible for curative or even diagnostic 
purposes. 

The statement that a real observance of asepticism offers a sure guaran- 
tee against suppuration, be the performance of a bloody operation however 
clumsy, rough, and unskillful, is true, but can not be pleaded as an excuse 
for the absence of that equipment of pathological and anatomical knowledge 
and technical skill which go toward forming a good surgeon. Although 
the general standard of safety and success in surgery has been considerably 
raised, excellence will be attained by those only who unite the qualities of 
a good diagnostician, pathologist, and anatomist with the tact, energy, and 
technical skill of the accomplished surgeon. 

The technique of surgical dissection is based upon principles, the ob- 
servance of which enables us to safely explore and manipulate any accessible 
part of the human body. 

Aside from the ever-present desideratum of preventing infection, the 
avoidance of accidental injury of important organs and the control of haem- 
orrhage first deserve attention. 

The principle of doing every step of an operation under the guidance of 
the eye, is the most important discipline of dissection to be acquired. It 
should never be sacrificed without the most stringent necessity. Its non- 
observance is the source of most that is embarrassing, appalling, and dis- 
astrous in operative work. 

Upon this principle is based the rule to always make an ample and ade- 
quate incision, which should be gradually deepened layer by layer, until 
the part sought after is freely exposed. 




Fig. 10.— a, Bellied scalpel for cutaneous incision, b, Sharp-pointed scalpel for deeper dissection. 



For the cutaneous incision a bellied scalpel, held like a fiddle-bow, is 
the most useful. A careful and clean incision will insure a lineal cicatrix. 
As soon as the skin is divided, the subcutaneous vessels will become visible. 
If they are crossing the line of incision, they should be grasped between 

two artery forceps, divided 
between, and safely tied 
off with catgut. In cut- 
ting through the fascia, the 
grooved director used to play 
an important part in for- 
mer times. Its use has been 

11. — Manner ot holding the knife for the cutaneous 

incision. supplanted by a safer mode 




Fig, 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



37 



of preparation, known as cutting betiveen two thumb-forceps. The author 
once observed that, in thrusting a grooved director underneath the fascial 
coverings of a hernia, the hernial sac was opened, and the adherent gut 
nearly torn through. As it was, only its serous covering was lacerated. In 
another instance, puncture of the deep jugular vein by the point of the 
grooved director happened, and led to very annoying haemorrhage from the 
deepest parts of the wound, which made exposure and ligature of the injured 
vein very difficult. It may be said that, unless very thin layers are taken 
up by the grooved director, the surgeon never can tell beforehand what he 
is going to cut through while using it. Veins especially are easily injured, 
as, being put on the stretch, they become empty. Stretched, they lose 
their identity to the eye, and look exactly like ordinary connective tissue. 





Fig. 12. 

Securing and tying v 



Fig. 13. 
traversing the line of incision. 



Cutting between two forceps has the peculiarity that, a thin layer of 
tissue being raised before each cutting, air enters into and rarefies its meshes, 
rendering clearly visible the vessels, which can be easily isolated and secured 
before they are cut. From this result two very great advantages : First, 
the patient does not lose one drop of blood from a vessel secured previous 
to its division ; and last, but not least, the wound remains dry and clean. 
No time is lost in hunting for a retracted vessel in a pool of blood, there 
is no occasion for hasty and rough sponging, and everybody preserves an 
easy tenor of mind very essential to success. 

The advice, so often met with in text-books, that the knife should be 
laid aside where the tissues are loose, and that tearing or scraping with for- 
7 



38 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

ceps or the finger-nail is safer, is, to say the least, very questionable. This 
advice is born of the fear of unexpected haemorrhage, which, however, can 
be always avoided by cutting between two forceps. The beginner, especially, 
is prone to carry this mode of blunt preparation to great lengths, and lacer- 
ation of large veins, the peritoneum, or cysts is the result. 




Fig. 14. — Cutting between two thutnb-forceps. 

A consideration of no small importance is the fact that a clean-cut wound 
will sometimes heal in spite of some local reaction and fever. This means, 
that the blood- and lymph-vessels of the parts concerned being not much 
bruised, sufficient nutriment is carried to the walls of the wound to over- 
come a moderate degree of micrococcal infection. Where the nutrition of 
the parts is seriously interfered with by tearing and bruising pertinent to 
blunt dissection, a much higher degree of asepticism is required to secure 
absence of suppuration. 

Note. — The old surgical tenet, that torn and bruised operative wounds are not prone to heal 
kindly, is based upon the fact that devitalized tissues form an especially favorable pabulum to 
microbial development. The observation that very well nourished tissues, as, for instance, those 
of the face, will heal readily under almost all circumstances, and without the observance of anti- 
septic precautions, is explained by the fact that they are very well vascularized, and a rich supply 
of oxygenated blood is one of the strongest germicides. We often saw the parts become red, 
swollen, and painful, and were expecting suppuration, but in vain, as all the local symptoms and 
the fever receded, and good union followed. 

As the wound is gradually deepened, sharp or blunt retractors should 
be employed to well expose to view its bottom, in which is centered the sur- 
geon's interest. The skin, muscles, fasciae, tendons, or the periosteum can 
be held back by sharp retractors ; vessels and nerves, the peritoneum, and 
friable glands or cysts should never be hooked up by them, blunt retractors 
deserving the preference. 

Most of the retractors commonly sold by the instrument-dealers are 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



39 



worthless. A useful retractor must 
have a good, ample curve, a propor- 
tionate and safe grasp, a smooth, solid 
handle, and a strong shank, so as to 
be able to sustain a good deal of press- 
ure without bending or breaking. 





Fig. 15.— Small 
blunt retractors. 



Fig. 16. — Medium-sized blunt 
retractor, a, Actual size. 



Fig. 17. — Large-sized blunt retractor. 
b, Actual size. 




Fig. 19. — Large four-pronged sharp retractor (Volkmann). 




40 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The shapes and sizes most useful for general surgical work are depicted 
by Figs. 15, 16, 17, 18, and 19. 

The deeper the knife penetrates, the nearer it approaches important 

organs, the shallower its 
strokes should become. 
A somewhat pointed 
scalpel should be used, 
and its strokes, especial- 
ly where they sever dense 
tissues, should be made 
with the very point of the 
instrument, which should 

Fig. 20.— Manner of holding the knife for deep dissection. be held like a pen, but 

rather steeply. 

Use of the grooved director, or the scissors, or the sickle-shaped bistoury 
in the bottom of a deep wound is always unsafe, as it may lead to unex- 
pected haemorrhage or something worse. Especially dangerous is the last- 
named instrument, as its very nature renders impossible the observance of 
the principle of not cutting what we do not see. It cuts from within out- 
ward, takes up unseen tissues, and may become the cause of unnecessary 
trouble and embarrassment. 

Should it become evident, as the wound deepens, that the first incision 
is inadequate, and that, in order to afford access, its edges must be subjected 
to severe tension, and that work is thereby cramped, an extension of the 
first incision is in order. This should be done methodically from without 
inward until the wound is sufficiently enlarged. 

Note. — The author once saw an ovariotomist make abdominal section with exaggerated 
minuteness, layer by layer, until the belly was opened, tying each small vessel as it was exposed. 
When a digital exploration had made evident the insufficiency of the incision, he enlarged it by 
cutting through the entire thickness of the abdominal wall with a stout pair of scissors at one stroke. 
Of course the incision was uneven, some layers being further cut than others, haemorrhage was 
considerable, and finding and securing of the retracted vessels not easy. 

The shape of every operation wound should be such, if possible, as to 
afford the best conditions of access, 

and, later on, for natural drainage. <CZ C ~Z ^ /' A 

The funnel shape (Fig. 21, a) is \ / /'' X N 

meant by this — that is, that the first 

incision should be the longest, the \ / \ j 

next one a little shorter, the last one \___/ 

the shortest. Even if no drainage- A B 

tube is inserted in such a wound, as FlG - 21 '~ A ' F T4;lTounT nd ' *' B ° ttle " 

long as the closing stitches are not 

too tight and too many, the interstices of the suture will afford ample 

drainage. 

Bottle-shaped wounds (Fig. 21, b) are disadvantageous in every way. 
They result from a too small cutaneous incision, are uncomfortable and 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



41 



unsafe during the operation, and after closure offer poor conditions for 
natural drainage. They always require a drainage-tube, and, eTen with a 
tube, if not absolutely aseptic, become a very hot-bed of suppuration, as the 
discharges of infected recesses may not find ready egress. 

Where the incision must be carried through condensed or inflamed tis- 
sues, preparation between two forceps will be generally impossible. All 
the more stress should be laid upon the amplitude of the first cut. and upon 
the adequate dilatation of the wound by serviceable and solid retractors. As 
the wound deepens, the hooks should be alternately released and inserted 
deeper, so as to follow up closely the work of the knife. 

On account of their hyperaemic state and density, haemorrhage will be 
found a great deal more profuse in inflamed than in normal tissues. The 
presence of vessels will become manifest only by the haemorrhage caused in 
cutting them. The smaller arteries can be easily controlled by increasing 
the tension exerted by the retractors on the edges of the wound. Larger 
vessels must be tied off. But the density and often the brittleness of the 
tissues prevent grasping of 
the bleeding points with 
artery-forceps, hence an- 
other expedient must be 
used. 

An ordinary curved, or, 
better, a perfectly round 
haemostatic needle, armed 
with catgut, is carried with 
a needle-holder through the 
tissues adjacent to the bleed- 
ing point in two or three 
stitches, so as to surround it 
bleeding orifice. 




Fig. 22. 
Haemostatic 

needle. 




Fig. 23. 



•Manner of applying haemostatic 

needle (Esmarckj. 



like a purse-string. Being tied, it closes the 




Fig. 24. — Dieffenbach's needle- holder. 



When a plexus of considerable vessels, especially veins, is encountered 
in the bottom of a wound, or where, for some reasons, it is desirable to 
hasten operative work, the employment of mass ligatures will be found an 
expedient and safe way to rapid progress. 

Thiersch' 's spindle and forceps is an invaluable apparatus for applying 
mass ligatures to dense tissues in difficult and deep situations. A blunt, 
probe-pointed, curved needle and a straight ivory spindle, armed with stout 
silk or catgut, and an appropriate forceps, make up the apparatus. The 



42 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



probe-pointed needle is grasped by the beak of the forceps, and is cau- 
tiously insinuated under the plexus or mass to be tied off. Veins and 
arteries are not apt to be injured by the blunt point, as they are inclined 
to slide off from it. As soon as the ligature thread is drawn through under 
the mass, a knot is made, and, the spindles serving as solid handles, it can 
be tightened with a great deal of firmness and security. The mass can be 
safely divided between two of these ligatures. 

The treatment of veins in operative wounds 
is similar to that applied to arteries. There are 
some points, however, that constitute an impor- 
tant difference, and deserve special attention. The 
tension exercised by retractors is very apt to ob- 
literate the normal characteristics of veins. The 
dark blood they contain is driven out of them, 
and they can not be distinguished from ordinary 
connective tissue. Especially in blunt prepara- 
tion, lacerations of veins are apt to occur and 
cause serious difficulty. To find a bleeding vein 
is not as easy as to locate an injured artery, readily 
marked by its jet of blood. And, even if the 
bleeding point is recognized, it is not always easy 
to stop a torn vein, as the laceration may be, and 
in fact frequently is, an irregular and extensive 
slit. On the other hand, venous haemorrhage can 
often be effectively checked by simple pressure or 
plugging. If the finding of a torn and retracted 
vein should be difficult and involve too much 
time, it will be found a good expedient to plug 
up the place from which the haemorrhage issues 
with a strip of iodoformed gauze, held in place 
by light finger-pressure until coagulation occurs. 
Formerly the author used a bit of sponge for this 
purpose, but the following experience has shown that sponge is not a safe 
material : 




Fig. 25. — Thiersch's spindle 
apparatus. 



Case. — Theresa Kops, housewife, aged forty-eight. February 10, 1883. — Ampu- 
tation of left breast, with evacuation of the contents of the axilla for scirrhus of the 
mammary gland. Wound sutured throughout; drainage by counter-incision through 
latissimus dorsi. Aseptic dressing. After feverless course, first change of dressings 
on February 21st, when the wound was found united. Drainage-tube was withdrawn. 
Feb. 22d. — Severe chill, phlegmonous infiltration of axillary region. Feb. 23d. — Incis- 
ion through cicatrix, and evacuation of a large quantity of pus, followed by a small 
fragment of sponge ; drainage. Uninterrupted healing of the axillary abscess by 
granulation. 

In removing the axillary glands a small vein was put on the stretch, 
and, being ruptured, retracted so far that it could not be found. A good- 
sized sponge was stuffed temporarily into the recess from which the haemor- 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 43 

rhage issued, and the operation was finished. When the sponge was ex- 
tracted, it came away, as usual, with some resistance, due to the matting 
of the blood-clot into its meshes. The sponge was a yery soft and brittle 
one, and its own cohesion was apparently less than the cohesion of its 
surface to the tissues matted to it. A small portion of the sponge tore off 
and was left behind in the wound. It caused no trouble for eleven days, 
and only after the disturbance of its relations by the removal of the drain- 
age-tube did its decomposition set in. Since that time a strip of iodoformed 
gauze was used for the mentioned purpose by the author, which would not 
tear, and could not be overlooked, as its end is carried out of the wound 
for a mark. 

Close attention to the details enumerated above will secure a dry and 
easily accessible wound. No sudden and uncontrollable haemorrhage will 
occur to create flurry or alarm ; no embarrassment will cause undue haste 
or an ill-considered move ; the patient will fare well, as, even with the seem- 
ing deliberation, the operation will be speedily accomplished, and, what is 
the main thing, no unnecessary loss of blood will be sustained. 

n. SUTURES. 

Primary union with a linear cicatrix is the ideal of the healing of an 
aseptic wound. As it depends to a great measure upon an exact coaptation 
of its edges in such a manner, that circulation of the integument should not 
be interfered with, and as exact coaptation under varying circumstances 
requires a variation of the procedure, a discussion of the important differ- 
ences in the technique of suturing may receive some consideration. 

Exact coaptation of the corresponding points of the edges of the wound 
by finger-pressure or otherwise, before and ivhile passing the stitch, is the 
first condition of a true suture. Where there is no considerable loss of 
integument, and where the edges of the wound are equally thick and have 
sufficient body, this can be done easily by compressing the edges between 
the index and thumb until they touch on the same level. A good-sized 
curved needle is then passed through both edges of the wound, which 
will be retained in their correct relation by simply tying the catgut 
thread. 

Where one of the edges is thick and the other rather thin, coaptation 
is more difficult, as the thinner edge is apt to slip back, leaving a portion 
of raw surface exposed. Or where both edges of the wound are thin, as, 
for instance, on the neck, the scrotum, and the dorsum of the hand or 
foot, they have the tendency to curl under, raw being in contact with epi- 
dermidal surface. Both of these relations will produce an uneven line of 
suture, and will frustrate exact primary union. Partial healing by granula- 
tion is then unavoidable. 

Under these circumstances the best result will be achieved by the fol- 
lowing plan : The edges of the wound are brought together and pinched 
up by index and thumb in such a way as to form a continuous ridge, on 



44: 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 26. 



the top of which should appear the line of incision. A straight needle is 
thrust transversely through the base of this ridge, and the suture is tied 
while the fingers still retain their position. The appearance of the com- 
pleted suture is rather grotesque ; but, 
when the stitches are absorbed or re- 
moved, the peculiar-looking ridge will 
flatten out spontaneously, and the re- 
sult will be a beautiful fine cicatrix. 
See Figs. 26 and 27. 

In tying a surgical knot, a certain 
little knack will be found extremely 
useful, especially where good assist- 
ance can not be had. It consists in 
jamming down the first or double knot 
into the angle of the suture nearest to 
the operator by a slight jerk, made upon the distal end of the thread, while 
the mesial one is held steadily on the stretch. This jamming of the catgut 
will be just sufficient to hold the edges of the wound together, until the 

second knot is tied. It will 
even hold together edges ap- 
proximated with some degree 
of force. 

Where there is much loss 
of integument, as in many 
cases of breast amputation, 
or where the sutures may 
have to stand a good deal of 
strain, as, for instance, the 
abdominal stitches after ova- 
riotomy, aside from the su- 
tures of coaptation above 
mentioned, supporting or re- 
tentive sutures are necessary. 
They have to embrace a 
good deal more integument 
than the finer stitches, and 
should be inserted from one 
half to two inches away from 
the edges of the wound. Lat- 
eral concentric pressure by the hands of an assistant will very much facili- 
tate the proper placing of these sutures. 

They can be made in several ways. The simplest one is to pass three 
or four or more interrupted catgut sutures of wider scope, and then to tie 
them while the edges of the wound are firmly supported by an assistant 
(Fig. 28). The required number of finer stitches is passed afterward. An- 
other good way is the application of a mattress suture, illustrated in Fig. 





W^^^\ I 




^JpL ,«5 




..^..^^?f rJkjZm.^-:. ■?.. *<£ 




W0- 



Fig. 27. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



45 



29, combined with a continuous coaptation suture, all done with one piece 
of catgut. 

Where silver wire or silkworm-gut are available, the quill suture or 
Lister's plate suture will give much satisfaction. Both of these forms of 




Fig. 28. — a. Interrupted retentive suture. 




Fig. 29. 



-Combined mattress suture and Glover 
stitch. 



retentive suture will be very proper after abdominal operations. For the 
quill suture, small cylindrical pieces of well-disinfected wood will an- 
swer. Plates for Lister's retentive suture (Fig. 30) are cut out of stout 
sheet lead with a pair of scissors. It is sold by dental-supply traders 
under the name of "suction lead." The wire or gut is armed with a per- 




«(V) 



0, 



—*b 





Fig. 30. — a. Plate and shot suture. 
b. Interrupted suture. 



Fig. 31. — a. Catgut suture from suppurating stitch- 
hole, b. Catgut from *.sweet stitch-hole, nearly 
absorbed. 



forated shot, which is clamped to its end ; over this is slipped a plate. The 
suture is passed, and the needle is unthreaded. Over the second end a 
plate and shot are slipped, the stitch is tightened, and the shot is clamped. 

In uniting more extensive wounds, it is better to commence at the mid- 
dle and not at the angle, as the latter way may result in uneven distribu- 
tion and puckering. 

After abundant trial and comparison, the conclusion was arrived at by 
the author that, as a rule, the interrupted suture is in every way preferable 
to the continuous one. The exceptions are mentioned at the proj)er place. 

The chief advantage claimed for the continuous suture — namely, the 
saving of time — is illusory. As regards safety in holding and exactitude 
of adaptation, the interrupted suture has no peer. 



in. DRAINAGE. 

Small aseptic wounds of a favorable, that is funnel shape, do not re- 
quire drainage by rubber tubing. As few stitches should be taken, how- 
ever, as possible, to permit the escape of the oozing between them. Small 




46 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

wounds of bottle shape will do very well with a few threads of catgut placed 

in one angle for capillary drainage. Larger wounds, especially those with 

a sinuous cavity, require drainage by rubber tubing. 

Before using the tube, a number of oval holes should be clipped out of 

its side. 

" Through drainage" with a view to subsequent irrigation, is best 

effected by placing the mesial end of the tube just within the cavity to 

be drained. Drawing 
a long piece of tubing 
transversely through the 
cavity does not afford 

Fig. 32.— Perforated rubber drainage-tube. tne Dest Conditions for 

thorough irrigation, as 
the bulk of the irrigating stream will pass directly through the tube with- 
out entering the cavity at all. Where two or more short pieces of tubing 
are placed just within the cavity, the entire mass of the irrigating stream 
is thrown into the cavity, to escape through the opposite opening only after 
having washed the entire extent of its interior. 

Aseptic rubber tubes never cause "irritation." Increased discharge or 
irritation of any kind is due to infection introduced into the wound by 
means of the tube at change of dressings. If the withdrawn tube is 
touched by unclean hands and is then reintroduced, it is apt to cause irrita- 
tion. But it is not the tube but the dirt adhering to it that is the cause of 
the trouble. 

The persistence of sinuses after certain operations, notably exsections, 
was also attributed to the use of drainage-tubes. This mistake is now ex- 
plained by the knowledge, that the sinuses in question do not heal on 
account of reinfection by tubercle bacilli, extending along the tubes with the 
discharges from an incompletely evacuated tubercular focus. 

In aseptic wounds, the office of the drainage-tube is performed by about 
the end of twenty-four hours after the operation. But other considerations, 
notably the unwillingness of disturbing the rest of the wound and of the 
patient, make it inexpedient to reopen the dressings so soon for the purpose 
of withdrawing the tube. It is generally left in situ until the first change 
of dressings. If there is no purulent discharge visible in the dressings 
removed on the sixth or tenth day, the tubes can be safely withdrawn. If 
the healing was not entirely faultless, as seen from the presence of more or 
less pus in the dressings, it will be safer to reintroduce a short piece of 
tubing for the purpose of keeping patent the external end of the tube-track 
until the discharges shall have become scanty and serous. 

When a wound is in good condition and no pyogenic or tubercular 
infection be present, the surgeon will find it a very difficult matter to keep 
a tube in place for a long time, should he desire to do so. The cicatrization 
of the deeper parts of the drainage-hole will irresistibly expel the tube, or 
granulations will invade the lumen of the tube through its lateral fenestra, 
and will simply fill it up completely. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 47 

The tube should be always extracted for iuspection at the first change 
of dressings. If it is found to be filled up with a more or less solid clot of 
sweet blood or fibrin, the interior of the wound can be assumed to be in 
good condition. Should the clots be foul and semi-fluid, the tube must be 
shortened and replaced after thorough cleansing. 

The decalcified bone drainage-tubes, devised by Neuber, have been 
abandoned by the author on account of their many inconveniences not over- 
balanced by the advantage of their absorbability. 

Neuber's " canalization" that is, turning in of a part of the edge of the 
wound, and fastening it to a deep-lying part of the tissues by suture, still 
found a limited application in the author's practice, as will be seen in the 
chapters referring to it. 

It may be said, on the whole, that rubber tubing has so far not been 
supplanted by anything better for purposes of wound drainage. 

B. Application of Aseptic Method to Diverse Organs and 

Regions. 

I. LIGATURES OF ARTERIES IN THEIR CONTINUITY. 

With due observance of the rules of surgical dissection and of the land- 
marks pointed out by anatomy, the exposure and deligation of the larger 
arteries will present no serious difficulty. 

The treatment of the vascular sheath deserves some special remark. 

Free incision of the sheath will be found to facilitate very much the 
isolation of the vessel. No fear need be entertained of causing thereby 
necrosis or suppuration in an aseptic wound. 




Fig. 33. — Incising the vascular sheath (Esmarch). 

The sheath should be grasped and raised with a pair of mouse-tooth 
forceps, and the cone thus formed should be incised with the knife held 
horizontally. The incision can be extended to half an inch in length. See 
Fig. 33. 

Isolation of the vessel is best accomplished by gently insinuating into 
the slit the point of a bent silver probe, while the edge of the cut is held up 



48 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

by the mouse-tooth forceps. As soon as the point of the probe emerges on 
the opposite side of the artery, it is followed up by an aneurism-needle 
armed with a catgut thread, which is tied in a square knot. 

Encircling a vessel with an aneurism-needle having a sharp or even a too 
slender point may lead to piercing of the artery wall by the instrument. 

Case I. — Carl Tompert, carpenter, aged forty, noticed in October, 1881, a pulsating 
swelling on the left side of his neck. By February, 1882, it had attained the size of a 
goose's egg. March 2d. — Ligature of left common carotid between the heads of the 
stern o-mastoid muscle at the German Hospital. In passing aneurism-needle under the 
artery without the exertion of unusual force, suddenly a jet of arterial blood was seen to 
spurt up from the wound. Traction on the aneurism-needle controlled the haemorrhage. 
A catgut ligature was passed around the artery above and another below the aneurism- 
needle, and both were tied. The artery was divided between the ligatures, and then 
it was ascertained that the aneurism-needle had made a longitudinal slit into the 
artery wall. No drainage-tube was used, and the wound was closed by a few catgut 
sutures. Pulsation of the tumor had ceased, and subsequently it shrunk away to a 
stout cord-like structure. The wound healed by the first intention and no fever 
occurred, but the first two days following the operation very profuse general per- 
spiration was observed. Patient was discharged cured, March 20. 

In this and the subsequent cases, as well as in all other operations done 
by the author since 1877, catgut was used exclusively as ligaturing material 
with the greatest satisfaction. Only one case of suppuration occurred in 
which the infection could be traced to the use of impure catgut (page 8). 
Secondary haemorrhage or slipping of the ligature was observed twice 
(page 69). Even in suppurating wounds, catgut has been found to be a 
safe ligaturing material. It is in every way preferable to silk, and in no 
case was its use ever regretted. Those who have been accustomed to tie 
vessels with silk, usually employ too much force in tightening catgut liga- 
tures. They overtax the strength of the animal thread, and to their great 
annoyance constantly break it. A small amount of traction is sufficient to 
safely tighten the knot, as it is not necessary nor desirable to sever the inner 
coat of the artery. The many cuts, so common on the ulnar side of 
surgeons' fingers at the time, when silk was generally employed for tying 
vessels, are very rarely seen nowadays. To preserve its strength, catgut 
should never be immersed in any kind of a watery solution, as it is apt 
to become swollen and soft when brought in contact with water. The dish 
holding the ligatures at an operation should be dry, or should contain 
absolute alcohol. 

In all the cases here reported, no drainage-tube was used, reliance being 
placed on natural drainage. The catgut sutures employed were few and loose, 
and permitted a free escape of the oozing during the first twenty-four hours. 

Primary union of the wounds occurred in every case. 

Case II. — Herrmann Stinze, fishmonger, aged forty-six, admitted to German Hos- 
pital January 3, 1880, with aneurism of the femoral artery, situated just underneath 
Poupart's ligament, displacing it forward and upward. Syphilis admitted. Causation, 
severe effort at rowing fifteen months before admission to hospital. Direct compression 
of swelling was unsuccessfully employed for eighty hours. Jan. 17th. — Deligation of 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 49 

external iliac artery. No drainage-tube. Catgut suture. Prompt establishment of 
collateral circulation. Primary union. Discharged cured February 28th. Patient 
examined March 28th, when at the site of the aneurism a cord of the size of the middle 
finger could be felt. 

Case III. — Henry Green wald, clerk, aged fifteen. End of June, 1882, sustained 
stab-wound of left palm, followed by copious haemorrhage, which ceased spontaneously. 
Development of pulsating swelling of palm, which, by the direction of the family 
physician, was kept tightly compressed with a leaden bullet. Aug. 17th. — In the 
Oatskills severe arterial haemorrhage from pressure-sore over swelling, when bullet was 
removed and another compressory bandage was applied. Aug. 20th —Renewed haemor- 
rhage. Esmarch's band being applied, the clot was turned out of the open sore, the 
sac of the size of a hazel-nut was split and excised, and both afferent vessels were tied. 
Suture. Primary union followed. 

Case IV. — August M., agent, aged forty-one, suffering from progressed ataxia, 
cut his ulnar artery August 20, 1881, in a suicidal attempt. Haemorrhage was arrested 
by pressure made by a physician who attended to the patient immediately after the 
attempt. Aug. 23d. — Secondary haemorrhage. Esmarch's band being applied, the 
wound was dilated, and, the partially cut artery being exposed, was doubly tied and cut 
through between. Suture. Primary union. 

Case V. — Alexander Goerlitz, engraver, aged thirty-four. Had chancre eleven 
years ago, and had been in the habit of folding his legs while at work. June, 1883. — 
Noticed pulsating swelling in right popliteal space. Sept. 15th. — Circumference of 
left knee, thirteen, of right knee, sixteen and a quarter inches. Knee semi-flexed. 
Skin over aneurism dusky and hot. Esmarch's constrictor applied above and below 
swelling for an hour under ether without success, circumference increasing to seven- 
teen and a quarter inches. Sept. 19th. — Ligature of right superficial femoral artery in 
middle of thigh. Sept. 21st. — Swelling hard, non-pulsating. Paralysis of dorsal 
flexors of foot and of extensors of toes. No necroses. Primary union. May 17, 1881/,. 
— Knee can be fully extended, paralysis disappeared, muscles of leg have regained their 
normal bulk, tumor shrunken to a small, hard mass. 

Case VI. — August Bente, cigar-maker, aged fifty-one. No syphilis. In the sum- 
mer of 1883 felt neuralgic pains in right arm, followed by wasting of the brachial 
muscles, cyanosis, formication, and hyperidrosis of the extremity. In December 
severe dyspnoea supervened, and a pulsatile swelling under the right sterno-clavicular 
junction and in the lower cervical triangle was made out by Dr. John Schmidt, who 
directed the patient to the author, then on duty at the German Hospital. Aneurism 
of the innominate and subclavian arteries at their junction was diagnosticated, and 
simultaneous ligature of the right common carotid and the axillary arteries was per- 
formed January 16, 1884. The latter vessel was tied in Mohrenheim's triangle, just 
below the outer third of the clavicle. No drainage-tubes ; suture. Immediately after 
the operation the pulsation of the swelling became more pronounced, and for the next 
four weeks the shooting pains in the arm were much complained of. Both wounds 
healed by primary intention. Toward the end of February decrease of the swelling 
and moderation of the subjective symptoms became manifest. In March and April 
thirty hypodermic injections of Bonjean's ergotine were made in the abdominal region, 
and seemed to hasten the shrinking of the tumor. By May, the cyanosis, sweating, 
glossy skin, and formication, as well as the neuralgic symptoms, had very much abated, 
and the patient had gained ten pounds of flesh. Under massage, the application of 
faradism, and active exercise, the atrophy of the muscles had also materially improved, 
and in June the patient could resume his occupation. Nov. 11, 1881/,. — Patient was 
presented to the Surgical Society. Pulsation had almost entirely disappeared, and 



50 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

what there was of it seemed to be transmitted. Bruit was not noticeable. A 
well-perceptible fullness and resistance could still be made out in the right supra- 
clavicular fossa. Occasionally short and mild attacks of shooting pains were felt 
in the arm and nape of the neck. A claw-like deformity of the nails of the right hand 
remained unaltered. In August, pulsation and other signs of relapse were noted, 
with increasing pain, radiating toward the occiput. Eenewed injections of ergot were 
without avail. In October, during the author's absence from town, Dr. Adler incised 
an abscess pointing in the supraclavicular space, and a few days later performed tra- 
cheotomy for threatening asphyxia. A sharp pneumonia followed, from which the 
patient recovered only to succumb in November to sudden suffocation. No autopsy 
was permitted. 

Case VII. — John H. Nittinger, grocer, aged forty-five. No syphilis; had had 
articular rheumatism seven years before. Pulsating swelling of left popliteal space of 
the size of a man's fist. Leg had been oedematous for three months; marked emacia- 
tion. Jan. 20, 1885. — Ligature of left femoral artery in Scarpa's triangle. Primary 
union of wound. Recovery retarded by circumscribed necrosis of integument over 
tuberosity of calcaneum (due to pressure?). Discharged cured, March 30, 1885. 

Case VIII. — Emmanuel Luecke (see history on page 172). 

Case IX. — Robert Klaile, school-boy, aged fourteen. Congenital arterio-phlebec- 
tasiaof anterior part of left foot; pulsating, dusky swelling, of doughy feel, of dorsum 
and planta pedis. Along the course of saphenous nerve were seen a series of flat, hard, 
dark-blue, rough nodes, some of them as large as a silver quarter, their size tapering 
off toward ankle. Two of them were ulcerated and covered by a dry scab. Left foot 
on the whole larger than its mate. Pulsation of femoral arteries abnormally strong. 
Heart hypertrophied. Ablation of diseased parts was declined. July 7, 1885. — Liga- 
ture of superficial femoral artery. Short stoppage, and return of pulsation. Imme- 
diate ligature of external iliac of same side. Wounds sutured ; no drainage. Primary 
union. Necrosis of terminal phalanges of first and second toes, of the integument of the 
external side of leg, and of peroneus longus muscle. Scanty aseptic suppuration, and 
very slow detachment under antiseptic dressing. Tardy cure. The cicatrices on the 
toes became ulcerated in the winter, and the pulsation of the tumor, which had not 
diminished in size, had returned. Jan. 29, 1886. — Pirogoff's amputation. Unusual 
number of ligatures required on account of many abnormally large arteries. Cap of 
calcaneum was fixed to tibia by steel nail driven through from below. Catgut suture. 
Drainage through counter-incision alongside of tendo Achillis. No fever. First 
change of dressings February 19th. Primary union throughout, except where a narrow 
strip of the integument had necrosed along anterior part of incision. Dry dressing. 
Feb. 24th. — All firmly healed. Patient walks well without support. 

Note. — In exposing the external iliac artery, the small group of lymphatic glands found 
underneath the transversalis fascia, just above Poupart's ligament, may serve as an unfailing 
guide. As soon as these glands come to view, the peritoneum can be stripped up without diffi- 
culty. In incising a deeply situated perityphlitic abscess, the same glands serve as a good land- 
mark to prevent the operator from cutting into the fascia of the ilio-psoas muscle, which would 
divert him under the vessels. 

II. EXTIRPATION OF TUMORS. 

In removing tumors three requirements have to be commonly held in view : 
First, the avoidance of septic infection from without or from within. 
Secondly, the complete removal of the neoplasm. 
Thirdly, its safe removal. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



51 




Fig. 34. — Gluteal tumor betore extirpation. 



How to avoid infection from without was seen in previous chapters of 
this book, By infection from within, two kinds of infection are meant. 

One is the contamination by septic contents of the tumor that may escape 
into the wound through an accidental cut or a laceration of the tumor, 
caused by rough handling or 
the careless use of sharp re- 
tractors, as, for instance, in ex- 
tirpating suppurating glands. 

Case. — Sarah Barn, servant, 

aged sixteen; old Pott's disease 

of the cervical vertebra? ; large 

glandular swelling of right sub- 

maxillary region, with several si- 
nuses leading down toward the 

spine. It was pretty certain that 

no serious degree of the affection 

of the vertebrae could be present, 

as the function of the cervical 

spine was nearly normal. JSovem- 

ler 4, 1S86. — Flap incision and 

exsection of the large mass of 

tubercular glands at Mount Sinai 

Hospital. Though the utmost care 

was exercised in not grasping the 

glands with sharp-pointed instruments, one of them broke down, and poured out 

its contents into the large wound. As subsequent events demonstrated, seemingly 

thorough irrigation with a strong solution of corrosive sublimate did not disinfect all 

the parts of the wound. The dissection mainly extended into the intermuscular space 

— namely, the slit between the scaleni and the posterior border of the sterno-mastoid. 

After the removal of the mass, the 
finger was easily inserted into a 
track leading toward the second 
vertebra, the anterior surface of 
which was found rough and bare 
of periosteum. It was thoroughly 
scraped and irrigated (the instru- 
ment could be felt in situ from the 
oral cavity) ; the outer wound was 
drained, sutured, and dressed. Nov. 
5th. — High fever, with much de- 
jection. Skin below ear red, pain- 
ful, and swollen. The flap was re- 
opened, and a small abscess was 
detected just under the base of the 

flap, where probably irrigation had been insufficient. Open treatment. Temperature 

fell off to normal at once. The patient was discharged cured December 1st. 

The other kind of infection is the dissemination through the lymphatics 
of cancerous or sarcomatous cell-elements into the body caused by pressure 
due to rough manipulation of the tumor. 




Fig. 35. — Gluteal dressing. 



52 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Note. — It is a well-known fact that, in some cases of malignant tumor of slow growth, after 
operation, a large number of secondary nodes will spring up and develop with great rapidity in 
the neighborhood of the cicatrix. Two causes, either singly or combined, may be at the bottom 
of this phenomenon. 

Either the operation was incomplete — that is, the surgeon's dissection hugged the tumor 
too closely, leaving behind a number of outstanding microscopical foci, — or the forcible manipu- 
lations of the tumor during the operation have disseminated along the lymphatics and veins 
embryonal cell-elements of malignant character into the vicinity of the wound or throughout the 
body. This is commonly called " change of the character of a malignant neoplasm, due to 
mechanical irritation." 

Undoubtedly there are many cases where an incomplete operation leads to wide dissemina- 
tion of the elements of the neoplasm. In these cases relapse in the unhealed wound or in the 
fresh cicatrix is observed, together with the simultaneous appearance of regional and more dis- 
tant nodes of new formation. 

Thus an incomplete or rough operation may hasten instead of retarding the patient's death 
by generalization of the disease. 

Reasonable hope of the complete removal of a malignant new-growth is 
the main justification for operative interference. There is, to be sure, a 
considerable class of cases where complete removal is from the outset out 
of the question. Great discomfort from putrescence of a sloughing tumor 
or frequent haemorrhages do sometimes indicate partial removal. But, 
wherever possible, complete removal is to be aimed at by all permissible 
means, as the non-return of the disease depends solely upon the fulfillment 
of this condition. 

Our third object must be to remove the tumor with the least possible 
amount of immediate danger to the patient's life. Careful and deliberate 
dissection, guided by anatomical knowledge, limiting of the haemorrhage 
to a minimum, and avoidance of accidental injury to important organs, is 
meant hereby. 

The most important condition to be fulfilled in eschewing these dangers 
is an adequate incision. 

A too large incision never can do any harm, its worst consequence being 
the necessity for a few more suture-points. An insufficient incision, on the 
other hand, may be the source of great danger to the patient, and of much 
embarrassment to the surgeon. 

When the incision is ample, the new-growth and its connections can be 
readily exposed without the use of much traction from sharp or blunt hooks, 
and forcible grasping and dragging to and fro of the tumor itself will be 
unnecessary. Most of the vessels that are to be divided will be noticed, and 
can be cut between two artery forceps without loss of blood. Accidentally 
injured vessels can be easily secured and tied off. 

The wretched expedient of digging a malignant tumor out of its capsule, 
and leaving behind the latter, should never be resorted to, as a speedy 
relapse is certain to follow. 

Dissection should be done altogether with the knife, and exclusively 
in healthy tissues. Blunt methods of preparation are not to be used at 
all, since they are unnecessary, and involve a certain amount of rough 
force. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



53 




Fig. 36. — Axillary tumor before extirpation. 



In removing infiltrating or illy defined malignant new-growths, the sur- 
geon's knife should give the tumor a wide berth, and all cosmetic or func- 
tional considerations not involving present danger should be disregarded, 
the first object being the complete eradication of the disease. 

In an ample wound the tu- 
mor can be handled with the ne- 
cessary gentleness, and the main 
attack can be directed upon its 
adhesions to the surrounding tis- 
sues. 

With rare exceptions, sharp re- 
tractors are never to be plunged 
into the tumor. They should be 
used on the edges of the wound 
for dilatation, the tumor itself 
being held by hand through- 
out. 

The softer the mass of the tu- 
mor, the more care must be exer- 
cised not to injure it. Cysts especially require very tender treatment. 
Lipomata and fibromata will stand a good deal of rough handling with- 
out harm. 

Note. — In former days lipomata used to have a bad reputation. It was said that their 

extirpation was often followed by erysipelas and phlegmon. One of the first operations ever 

witnessed by the author was done upon a healthy young man in 1868 in Prof. D.'s clinic, at 

Vienna, for a lipoma of the shoulder. It caused the patient's death 

from septicaemia. This peculiarity, noted by surgeons in times gone 

by, was undoubtedly due to 
the readiness with which a 
phlegmonous process will 
spread in loose and ill-nour- 
ished adipose tissue. Of 
course, the infection always 
came from the hands and 
apparatus of the surgeons 
themselves. 

Where should dis- 
section first be direct- 
ed to, is a question 
that puzzles every be- 
ginner, and it is not in- 
different from which 
side we approach a 

tumor. Surgery owes to Langenbeck a clear exposition of the principle 

which should guide us in this matter. 

In excising tumors holding close relations to large vessels, as, for instance, 

those in the neck, axilla, and in Scarpa's triangle, the greatest safety lies in 




Fig. 37. — Axillary wound, united, after extirpation of tumor. 



54 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



first exposing these vessels above and below the tumor, so as to have full con- 
trol of them during the subsequent steps of the operation. This precaution 
offers great security against injury of those vessels, and at the same time 

reduces to a minimum 

the otherwise formida- 
ble dangers of such ac- 
cidental injury, should 
it occur. If it become 
evident that the tu- 
mor has involved the 
walls of the adjacent 
large vessels, a ligature 
above, another below 
the growth, will per- 
mit of a safe and com- 
plete exsection in one 
mass of the tumor and 
the diseased parts of 
the vessel. 




Fig. 



-Flap incision for removal of tumor of neck, 
drained and sutured. 



Wound 



Note. — It is the common tendency of young surgeons to carry too far the dissection of 
a vessel adhering to a tumor. This is actuated by the desire of preserving the integrity of the 

vessel in question, and by the natural disinclination 
of complicating the operation by double ligature, 
which again involves extra dissection. The con- 
sequence of this 
tendency may be 
twofold : either 
portions of the 
tumor adhering 
to the vessel wall 
are left behind to 
cause speedy re- 
lapse, or the vein 
is cut or torn. 





Fig. 39.— Dressing for neck wounds. 



Fig. 40. — Dressing of neck wound completed 
by rubber-tissue bib and arm-sling. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 55 

Whenever the surgeon has succeeded informing a pedicle to a tumor situ- 
ated in the vicinity of large vessels, cutting of such a pedicle without first 
tying it off is a very risky step. Traction upon the tumor will obliterate 
any vessels included in the pedicle, and, when cut, the innocent-looking 
mass, closely resembling ordinary connective tissue, may open up into unex- 
pected and overwhelming springs of welling blood. The stump will at once 
retract, and finding and securing the retracted vessel in an inexhaustible 
pool of blood is a terribly difficult, sometimes impossible, thing. Should it 
be an artery, the tips of two or three fingers must be thrust at once into the 
place from which the haemorrhage is issuing. The blood must be mopped 
up by rapid sponging, to enable the surgeon to find the vessel, in order to 
secure it with an artery forceps, or to surround it by a suture passed through 
the adjacent tissues. His mettle will be put to the severest test, and it 
will be a lucky day if his patient do not succumb on the table. 

In trying to secure the stump of a large vein accidentally cut across, the 
wide extent of its circumference will offer much difficulty, as an ordinary 
artery forceps is too small to take in the entire lumen of the vessel. One 
or more great leaks will remain, even if the vessel be fortunately grasped by 
one forceps. Two, three, or more additional instruments have to be brought 
into requisition till the end is accomplished. The haste, natural and 
almost unavoidable on such occasions, will easily lead to further tearing of 
the soft w^alls of the vessel, and, finally, salvation will have to be sought in 
plugging with iodoform gauze. 

Here, like in other things, prevention is much easier than cure. 

Lateral tearing or slitting of a large vein is another accident to which 
may lead disregard of Langenbeck's rule. There are two ways out of this 
contingency. One is to expose and deligate the vein 
above and below the laceration, while the fingers of an 
assistant compress the injured part of the vessel. The 
other one is the application of a lateral ligature or a con- 
tinuous suture of fine catgut occluding the rent. 

Both of these latter methods, however, are difficult 
and not very reliable, though they have succeeded in the 
hands of several surgeons, including the author's.* 

They were bred of the fear of tying large veins, for- 
merly so prevalent on account of the dangers of phlebitis 
and, in the extremities, of gangrene. In cases where a 




-/> 



Fig. 41. — Lateral lig- 

large portion of the vein wall is lost by sloughing or cut- ature andcontinu- 
ting, and the resulting aperture is very large, lateral liga- SedVein! 0± m ~ 
ture and suture are impossible. Whenever feasible, a 
double ligature should be applied, whether it concerns the deep jugular or 
axillary and femoral veins. Langenbeck's advice to tie the acconrpanying 
large artery has been much impugned lately, as it was found that gangrene 

* In a case of exsection of lymphomata of the neck, done in 1880 in the German Hospital, 
where the deep jugular was injured. The patient recovered. 



56 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of the extremity followed its adoption. On the other hand, a growing num- 
ber of cases are on record, where deligation of the femoral or axillary vein 
led only to temporary disturbance of no great import. 

Case. — Henry Rickriegel, carpenter, aged twenty-three, admitted to German Hos- 
pital, March 2. 1887. Two days later the house-surgeon extirpated a mass of sup- 
purating glands from Scarpa's triangle of the right side. The 
saphenous vein, which passed into the tumor from below, 
was tied and cut across. Likewise were treated a number 
of larger veins entering the tumor from above. The femoral 
vessels were not exposed, but the 
pulsation of the artery could be 
distinctly felt, and it was care- 
Finally, the 




Fig. 42. — Periosteal myxosarcoma of thigh before removal. 

mass was freed all around, until a stout pedicle was formed, which was seen entering 
the oval foramen of the fascia lata. This pedicle was tied with catgut and was cut 
through. In the mean time the patient had be- 
come semi-conscious and began to struggle, where- 
upon, suddenly, an enormous jet of venous blood 
was seen to well up from the bottom of the wound. 
The operator plunged his fist into the pool of 
blood, and thus succeeded in checking the haemor- 
rhage until Dr. 
Bachmann, the 
chief of the house- 
staff, appeared, 
who luckily suc- 
ceeded, with the 
aid of Thiersch's 
spindles, in pass- 
ing two ligatures, 
one below, the 
other above the 
bleeding point, ef- 
fectually stopping 
the formidable 
loss of blood. Im- 
mediately, deep 

cyanosis and oedema of the lower extremity developed, and the author, who saw the 
patient directly after the operation, ordered elevation of the limb, which was brought 
about by its vertical suspension in a wire cradle. March 5th. — Cyanosis disappeared, 




Fig. 43.— United wounds after removal of myxosarcoma of thigh. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



57 



oedema much diminished. Temperature, 101 '5°. Circulation of limb good. The 
wound did well, but, March 18th, temperature rose to 103° Fahr., and signs of phlebitis 
of the femoral vein in the middle of the thigh appeared in the shape of a cylindrical, 
painful, and hard infiltration. This and a number of similar attacks were subdued by 
the application of an ice-bag. The persistent oedema was combated by elastic com- 
pression with Martin's bandage, supplemented later on by massage. May 15th. — The 
patient was discharged cured, very little of the oedema being still noticeable. 

In this case, apparently, a portion of the trunk of the femoral vein was 
drawn into the cone of the pedicle containing the root of the saphenous 
vein, and was excised along with the tumor. 

The ligature slipped off, and a wide gap was opened in the side of the 
femoral vein corresponding to the place of entrance of the saphena. The 
peculiarity of the walls of large veins to yield to lateral traction is well 
known to surgeons, and is a just source of anxiety, as the extended vein 
becoming empty can not be recognized. 

Double ligature of the vein will be insufficient to check the haemorrhage 
when a large branch inosculates between the two ligatures. Such branch 
must be separately exposed and tied. 

Case. — March 27, 1880, the surgeon in charge of the ward for syphilis and skin 
diseases at the German Hospital excised a large glandular tumor from Scarpa's tri- 
angle on John Te G-ernpt, aged twenty-four. The 
operation was finished without accident, and, ac- 
cording to the then prevailing custom, the wound 
was mopped with an eight-per-cent solution of chlo- 
ride of zinc. April 11th. — A large slough of the 
vein wall was detached, and fear- 
ful haemorrhage ensued, which 
Dr. Loewenthal, the house-sur- 
geon, could not check complete- 
ly by local pressure. When the 
author saw the patient, he was 
nearly exsanguinated, though 
conscious. No pulse could be 
felt. Without anaesthesia the 
femoral vein was exposed below 
the opening in its wall, while pressure by three finger-tips completely controlled 
the haemorrhage. 

Note. — Thrusting of the fist or of a sponge into the wound will not check haemorrhage 
effectually in these cases. The tips of the fingers pressed exactly upon the bleeding orifice, and 
without much force, will always succeed in controlling the vessel. 

As the vein bled from above, too, Pouparfs ligament was cut across, and the external 
iliac vein was tied. After this the loss of blood became very much diminished, but a 
considerable vein inosculating just opposite the defect in the wall of the femoral vessel 
required separate exposure and deligation, whereupon the haemorrhage ceased com- 
pletely. Unfortunately, the total loss of blood had been so considerable that the patient 
survived the operation only a short time, and died in collapse from acute anaemia. 

Deligation and partial exsection of the axillary vein for ingrowing cancer 
of the axillary glands has been often performed by various surgeons with 




Fig. 44. — Dressing after removal of myxosarcoma of thurh. 



58 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



entire success, and can he undertaken ivithout hesitation whenever un- 
avoidable. 

In deligating the deep jugular vein, avoidance of the pneumogastric nerve 
will require close attention. When there is enough space to expose and 
liberate the vein freely, this will not be found very difficult. Low down at 
the root of the neck however, the decision of the question whether the 
ligature encompasses the nerve or not may occasionally be impossible. 

Case. — Mrs. Catharine Phmkett, aged sixty-four. Extirpation of recurrent lympho- 
sarcoma of neck, December 22, 1886, at Mt. Sinai Hospital. A tumor of the size of 
a hen's egg was located low down in the supra-clavicular fossa. Though it was freely 
movable, its close relation to the large cervical vessels was anticipated. A flap incis- 
ion and careful dissection laid bare the jugular vein above and below the tumor, when 
it became evident that it would be impossible to remove it without excising a correspond- 
ing portion of the vein. The lower ligature had to be applied somewhat behind the 
sterno-clavicular rim, and on account of the lack of space this was very difficult. Isola- 
tion of the vein had to be done with the greatest caution to avoid its injury. Finally 
a silver probe wormed its way around the vein, and the question arose, Was or was 
not the pneumogastric nerve inclnded in the ligature? To test tins the thread was 
firmly tied in a single knot. No change whatever of the respiration or pulse being 
noted, it was assumed that the nerve was not caught, whereupon a double ligature was 
passed through by means of the first thread, and, being tied, the vein was cut across. 
But on inspection of the mass it became clear that the nerve was included in the liga- 
ture and had been cut through. The tumor was easily dissected up after this until a 
pedicle was formed containing the jugular vein from above. This being tied, the 
tumor was removed. Drainage, suture, and dressings were applied in the usual 
manner. The patient recovered without one untoward symptom. Dec. 31st. — The 

first dressing was removed, together 

with the drainage-tubes. Jan. 3, 

1887. — She was discharged cured. 

Having thus gone through 
the entire subject, we may sum 
up in the following points : 

To accomplish a thorough and 
at the same time safe removal of 
a tumor located in the vicinity 
of large vessels, an adequate, that is, very ample, in- 
cision is absolutely necessary. 

Note. — On the trunk and the extremities, straight incisions, with 
the addition of a transverse extension, will be found most convenient. 
Where a transverse cut is inopportune, considerable gain in space can 
be effected by undulating the line of incision. 

In Scarpa's triangle, but especially about the neck, flap incisions are the most convenient. 

Methodical dissection, guarded by as many preliminary double ligatures 
as necessary, will insure a steady and uninterrupted progress of the opera- 
tion. Loss of blood will be minimal, and the flurry and haste incumbent 
upon profuse accidental haemorrhage will not lead, as it always does, to the 
disregard of the rules of asepticism. 




Fig. 45.— Outlines of flap 
incisions. 



Fig. 46.— a. T-shaped 
incision, b. Undu- 
lating incision. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 59 

Aseptic canons are easily forgotten during frantic efforts to check dan- 
gerous haemorrhage, although it is conceded that avoidance of suppuration 
is all the more important because of the injury to large vessels. 

After thorough irrigation and cleansing, the drainage of the cavity is 
to be attended to. It should be direct — that is, should reach the surface 
on the shortest possible route, if necessary through a counter-incision — and 
care must be taken of not letting the square inner end of the tube impinge 
upon a large artery. Especially must this point be heeded where the tube 
consists of hard material, as perforation of the vessel by friction against the 
hard edge of the tube is possible. 

Note. — There are cases on record where the innominate was ulcei'ated through by friction 
pressure of the margin of a tracheotomy cannula. 

The inner end of the tube should be placed so as not to touch the vessels, 
the general direction of the mesial end of the tube being parallel with them. 
To secure this position the inner end of the tube should be fastened to a 
suitable part of muscle or fascia by a catgut stitch. 

Change of dressings will be required, according to the size of the tumor, 
on from the sixth to the tenth clay, when the tubes can be withdrawn. 

III. AMPUTATION OF LIMBS. 

In performing a major amputation, the modern surgeon has to solve 
three problems : 

The first is to avoid septic infection of the amputation wound, or, if 
sepsis of the limb be present, to eliminate it. 

The second one is to limit haemorrhage to an unavoidable minimum. 

The third problem is to secure a good stump. 

1. Aseptics and Antiseptics of Amputation. — To the adoption of aseptic 
and antiseptic measures must be ascribed the remarkable reduction of the 
rate of mortality after major amputations, now prevalent wherever such 
measures are practiced. Formerly one third of all cases were directly lost 
mainly through primary septicaemia, or pyaemia, or indirectly by secondary 
haemorrhage due to ulcerative destruction. At present, deaths from acute and 
chronic blood-poisoning or secondary haemorrhage are very rare, and limited 
to cases that come under the surgeon's knife in a neglected or septic state. 

The total mortality, as computed from nearly 1,000 unselected hospital 
cases of various surgeons, treated on the new plan, is about fifteen per cent. 

The author's personal experience embraces forty-three cases of major 
amputation, mostly done in hospital practice. These were : 

Amputations of the thigh 22 

" " " leg 7 

" '' foot 1 

" " " shoulder 1 

" " '« arm 3 

" " " forearm 3 

Total 43 



60 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The amputations were performed : 

For suppurating compound fracture in . . . 2 cases 

" phlegmon in 6 " 

" acute and chronic osteomyelitis in 6 " 

" spontaneous gangrene in . . 5 " 

" incurable ulcers in 5 " 

" articular tuberculosis in 12 " 

" phlegmon from uratic arthritis in 1 case 

" malignant new-growths in 6 cases 

Total 43 " 

Of this number were cured : 

By primary union 16 cases 

" partial adhesion 14 " 

" suppuration 8 " 

Cured 38 " 

Died 5 " 

Total 43 " 

The five fatal cases were as follows : 

Case I. — Max Loffmann. Amputation of thigh at Mount Sinai Hospital for 
secondary haemorrhage due to phlegmon of popliteal space after exsection of knee. 
Patient came on table collapsed, and died immediately after ablation (see page 245). 

Case II. — Gustav Leuber, aged forty-nine. March 22, 1883. — Syme's amputation 
of foot, at the German Hospital, for tuberculosis of tarsus. Died May 5, 1883, of gen- 
eral marasmus, due to pulmonary tuberculosis. Wound nearly healed. 

Case III. — Carl Frank, aged sixty. Senile gangrene of foot and leg ; amputated at 
the German Hospital. On account of the collapsed and septic condition of the patient, 
twenty ounces of a six-pro-mille saline solution were transfused before commencing the 
amputation. The pulse rallied, and transcondylic amputation was done, but patient 
died immediately after the bone was sawed off. 

Case IV. — Louis Bourbonus, carpenter, aged twenty-nine. Acute progressive 
gangrenous phlegmon of hand and forearm. Septicaemia with petechial eruption. 
February 2 J/,, 1880. — Amputation of arm at the German Hospital. Patient died two 
hours after ablation. 

Case V. — Catharine Argast, aged fifty-four. Senile gangrene of fore part of foot 
September 18, 1882. — Syme's amputation at the German Hospital. Thrombosis of 
the femoral vein. Died, October 23d, of marasmus. 

The author's total rate of mortality would be 11*63 per cent. 

Excluding the hopeless and moribund cases Nos. 1, 3, and 4, the death- 
rate will be reduced to 4*65 per cent. 

Not one of the patients died of acute septicaemia or pyaemia clearly 
chargeable to the operation. Case No. 2 died of tuberculosis ; case No. 5 
(senile gangrene), of thrombosis due to general marasm. 

Considering the large proportion of amputations of the thigh (twenty- 
two), and the fact that ablation was done twenty times for acute septic pro- 
cesses under a vital indication, during a more or less pronounced state of 
general sepsis, the final results may be favorably compared with those 
achieved without antiseptics. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



61 



To further a better understanding of the methods employed for the 
maintenance of the aseptic condition during amputation, it will be neces- 
sary to class all cases requiring ablation in three groups. 

a. Clean" Cases. — The first group consists, on the one hand, of cases 
where amputation is indicated for various reasons, such as deformities, 
tumors, etc., in which the skin of the member is unbroken, and no sub- 
cutaneous, acute, or chronic suppuration is present ; on the other hand, of 
injuries requiring amputation, that come under treatment immediately 
after the accident. 

These are called clean cases. They require the ordinary aseptic precau- 
tions, such as shaving, thorough scrubbing, and disinfection of the field of 
operation, and a careful protection of the hands and instruments of the sur- 
geons from contact with non-disinfected parts of the patient's body. This 
is best accomplished by wrapping the whole limb, excepting the field of 
operation, into a swathing of disinfected towels, which should be fixed in 
position by safety-pins or a few turns of a roller-bandage. The patient's 

feet and hands, disinfec- 
tion of which is difficult 
at best, should never re- 
main unnecessarily ex- 
posed in amputations of 
the upper or lower ex- 
tremity. If the opera- 
tion is to be done near, 
or on the hand or 




these must be, if time permit, 

"rfSfcrtSS^ Clgy subjected to a careful prelim- 

tation of thigh. Al,..- inary process of cleansing. It 

consists of a prolonged bath 
of warm soap-water, and sub- 
sequent packing in compresses moistened with a two-per-cent carbolic solu- 
tion, and an external wrapping of rubber tissue to prevent evaporation. 
Large masses of epidermis will be soaked off in this manner, and can be 
removed by gentle friction with a brush or flannel rag in soap-water. This 
process must be repeated until the skin is perfectly clean, and does not shed 
epidermis. The part to be operated on is kept wrapped in a carbolized 
towel until anaesthesia is well under way, and the operation is about to begin. 
10 



62 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



- Esmarch's constrictor being applied, and the patient's body protected 
by rubber sheets, these and the parts of the limb not needing special dis- 
infection are covered with disinfected moist towels. The parts of the assist- 
ants are distributed, and every one takes his place. Now the surgeon 
unwraps the field of op- 
eration, and, having once 
more rubbed it off with 
corrosive-sublimate lotion, 
begins to operate. 

Frequent irrigation of 
the wound and especially 
rinsing of the hands of 
operator and assistants 




should not be neglected until the dress- 
ings are finished and the patient is ready for bed. The other precautionary 
detail mentioned in a previous chapter should also be carefully adhered to. 

With the exception of the saw, most instruments required for amputa- 
tion are easy to clean. The saw is a frequent medium of pyogenic in- 
fection. 

Case. — Arnold Bitter, mechanic, aged thirty-four, was amputated at the knee- 
joint eighteen years ago for a compound fracture of the leg. On account of insufficient 
covering, a large adherent cicatrix occupied the under and posterior side of the condyles, 
which were constantly ulcerated. Ee-amputation of the thigh above the condyles, 
January 8, 1887, at the German Hospital. Drainage and suture. Fever developed 
on the second day, rising to 103° Fahr. on the third, wherefore the house-surgeon re- 
moved the dressings, but found nothing to explain the pain and fever. On the fifth 
day the author inspected the stump, and found firm union of the flaps between each 
other and to the sawn surface of the bone, the drainage-tubes still filled with fresh, 
sweet clots, but the extremity of the stump decidedly club-shaped and oedematous, the 
oedema being of the deep-going, firm variety, characteristic of acute osteomyelitis. 
The stump was nowhere painful on pressure, except at a point corresponding to the 
upper margin of the sawn surface of the bone. In a few days pus began to exude 
from the drainage-tube placed through a counter-incision into the quadricipital bursa, 
and the patient's fever subsided. Feb. 9th. — The upper margin of the sawn surface 
was exposed and a narrow, sharp edge of necrosed bone was detected. This was 
chiseled away until healthy bone presented ; the fistula was scraped and the wound 
sutured. Primary union followed, and the patient was discharged cured, March 5th. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 63 

Apparently some filth was detached from the teeth of the saw when it 
was drawn across the bone the first few times, and became lodged near the 
upper margin of the bone section, causing there a circumscribed acute 
osteomyelitis, ending in necrosis. 

Note. — The proper way to cleanse a saw-blade is to scrub it thoroughly for five minutes in 
hot water with soap and a stiff brush, held across the blade, then to immerse it in carbolic 
lotion until used. It is best to do this as the last thing before the operation. Wiping with a 
towel should be avoided, as a number of linen fibers are detached thereby and remain adherent 
to the teeth of the saw. 

b. Mildly Septic Cases. — The second group contains cases character- 
ized by chronic suppuration, due to tuberculosis of joints or bones, or to 
ulcerative processes of various kinds requiring amputation. Infection of 
the amputation wound through contact with hands or apparatus that have 
touched the ulcers or fistulae, or through escaping secretions, occurs very 
easily in these cases, and special precautions have to be employed to avoid it. 

A careful examination of the affected parts should be made several days 
or a week before the time appointed for the amputation. Abscesses should 
be incised and drained, retentions removed by counter-incision, and the 
amount of secretion reduced by all known means, as, for instance, frequent 
irrigation and change of dressings. 

The field of operation should be prepared as indicated for the first 
group. Immediately preceding the operation the suppurating focus or 
ulcer should be irrigated and dressed in bed, and over the usual dressing a 
piece of rubber tissue should be tightly bandaged so as to overlap it on all 
sides, the margin of the gutta-percha adhering to the skin. 

The patient being anaesthetized, Esmarch's constrictor is applied, and the 
rubbers are arranged in the proper manner to shield the patient's body from 
drenching with the irrigating fluid. After this the whole surface of the 
limb, with the exception of the field of operation, is wrapped in clean 
towels, the carbolized towel covering the site of the operation is removed, 
this and all hands are finally disinfected, the irrigator is started, and the 
amputation should commence. 

It is not very difficult in these cases to exclude suppuration and to secure 
primary union by the exercise of a moderate amount of care and by intelli- 
gent attention to important details. 

Should infection occur on account of faulty management or the in- 
herent difficulty of the case, the inevitable suppuration will be mostly of a 
benign character, and well-nourished and well-coapted portions of the wound 
may even heal by primary union. 

Where amputation has to be done through ulcerating or suppurating 
parts of a limit, the surgeon has a still more difficult problem to solve. But 
even in some of these cases primary union can be achieved. Before com- 
mencing the operation, the skin surrounding the ulcer or sinus must be 
thoroughly scrubbed with brush, soap, and water, then the ulcer or sinus is 
repeatedly washed or injected with an eight-per-cent solution of chloride 
of zinc, and the granulations are thoroughly scraped off with the sharp 



64 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



spoon. Indurated or illy nourished tissues are removed, and all debris is 
washed away with the irrigating stream of mercurial lotion. After this the 
amputation is done as usual, good care being taken to provide for ample 
drainage. 

c. Septic Cases of Greater Intensity. — To the third group belong 
all cases in which an acute progredient septic process of spontaneous or 
traumatic origin necessitates ablation of the affected limb under a vital 




Fig. 49. — Securing of visible ves- 
sels by artery forceps. 

indication. Profusely sup- 
purating compound fract- 
ures, rapidly progressive 
phlegmons of the hand 
and arm, cases of embolic 
or other forms of sponta- 
neous gangrene, compose this class, in which the surgeon has to contend 
not only with the local trouble, but also frequently with a deep and dan- 
gerous general intoxication of the system, due to the massive absorption 
of ptomaines and bacteria. 

In many of these cases the processes determining phlegmonous destruc- 
tion have progressed beyond the highest limit of amputation, and securing 
of an aseptic state of the wound is impossible. No amount of irrigation 
will here do any good, and the surgeon, having removed most of what is a 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



65 



source of further infection, has to trust to good luck and the power of 
resistance of his patient, aided by ample stimulation and other restorative 
measures. In these cases the open after-treatment is in order. 

But, even in those instances where amputation can yet be done in 
healthy tissues, preservation of an aseptic state is an extremely difficult 
matter on account of several reasons. First of all, we have profuse secretion 
of pus or ichor, containing an extremely virulent culture of micro-organisms, 
a few individuals of which are sufficient to start up another phlegmon. 
Nobody who has not tried it can conceive the difficulty of keeping free 
from contamination in such cases. Another difficulty lies in the limits to 

our choice of the 
place of amputa- 
tion. When we 
can go high up, 
far out of the 
reach of the infec- 
tion, we should al- 
ways do it without 
regard to so-called 
conservative con- 
siderations. What 
is first to he' con- 
served here is the 
life of the patient, 
and before this 
view all objections 
ought to vanish. 

But, when the 
process has extend- 
ed up beyond the 
knee or the elbow, 
how keep free from 
contamination then ? True, the section 
may go through healthy tissues ; but, 
even with the greatest care, contact-in- 
fection is almost unavoidable. 

The measures to be employed in these 
cases are similar to those detailed for the 
second group, only with this difference : 
that attention to every step of the prepa- 
ration should be more rigid : that, if pos- 
sible, the filthy part of the preparation 
should be done by a separate person or 
persons ; and, finally, that the judicious use of our strongest antiseptics for 
irrigation (1 : 500 to 1 : 1000 of corrosive sublimate) is justified. The lotion 
used for rinsing the hands must be repeatedly changed, and everything that 




Fig. 50. — Compression of cut surface by 
sponges placed over the folded flaps. 
Removal of constricting band. 



66 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

has come in mediate or immediate contact with the focus of infection must 
be rigidly rejected. 

Amputation wounds belonging to this group should not be sutured, but 
require loose packing and moist dressings (open treatment). 

Our first and second groups coincide with "primary " and " secondary" 
the third with " intermediate " amputations. 

2. Hemorrhage. — Esmarch's apparatus and the animal ligature have un- 
doubtedly had a great share in bettering the statistics of major amputation. 

a. Artificial Aw^emia. — The most important and really blood-saving 
part of Esmarch's apparatus is performed by the constricting band, used 
instead of a tourniquet. The theoretical advantages of the use of the elastic 
roller-bandage, employed for evacuating the vessels of the limb, are offset by 
some serious drawbacks. It is an undeniable fact that the aerostatic press- 
ure will effectually prevent the escape of considerable quantities of blood 
from a limb, the circulation of which has been suppressed by central con- 
striction. Therefore, the expulsion of all the blood contained in a limb is 
not an absolute requirement of blood-saving in non-mutilating operations, 
as, for instance, joint exsections. 

In amputations the blood contained in the removed limb is an absolute 
loss, but its quantity can be effectually limited to a very small amount 




Figs. 51, 52. — Esmarch's artery forceps 





Fig. 53. — Harm's artery forceps. 



Fig. 54. — Showing 
the difference be- 
tween a, a good, 
and 5, a worth- 
less, artery for- 
ceps. On" com- 
pression, point of 
a remains in con- 
tact ; that of b 
gaps. 



by previous vertical elevation of the limb. And this loss is abundantly 
repaid by the agreeable assurance, that no septic material or infectious cell- 
elements, detached from a malignant new-growth, are thrown into the gen- 
eral circulation with the blood and lymph, which is expelled from the dis- 
eased limb by the elastic roller-bandage. 

The retention of a certain quantity of blood in the vessels of the stump 
affords additional advantages of no mean value. By pressure upon the 
stump, the smaller and smallest arteries and veins each will pour out a 
minute quantity of blood, which will greatly aid the surgeon in finding and 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 67 

securing them before the removal of the constrictor. Thus all considerable 
ostia can be occluded, so that, on detaching the rubber band, no spurting 
vessels will be observed, and the capillary oozing will easily be controlled by 
compression of the wound, aided by digital pressure 
exerted upon the main artery of the limb. Com- 
pression should not be done by packing the wound 
full of sponges, and folding the skin-flaps over these. 
True that their elastic pressure will check haemor- 
rhage. But, on the other side, most of the small 
thrombi occluding the vessels, that are continuous 
with the clot occupying the outer meshes of the 
sponge, are torn away when the latter is removed, 
and renewed oozing results. The same objection 
must be raised against vigorous sponging of the FlG - 55.— Manner of tying 
wound-surface. Even after oozing has stopped 

completely, frequent sponging is apt to renew it, and thus to prolong the 
time required for stanching the haemorrhage. 

A better way of employing compression is to fold the flaps over the wound, 
and then to arrange the sponges outside of them. This will insure the good 
effect of compression without the disadvantage mentioned above (Fig. 50). 

As soon as all visible vessels have been secured, the wound is compressed, 
and the constrictor is removed while the limb is held vertically. The assist- 
ant who removed the constricting band applies digital compression to the 
main artery. Immediately after removing the rubber band, the skin of 
the parts that had been subjected to artificial anaemia is seen to flush up, 
and to remain vividly red for from five to ten minutes. This is the period 
of excessive hyperaemia, due to paresis of the vasomotor nerves. Hyperaemia 
is all the more lasting and intense, the longer and the tighter was the con- 
striction. Attention should be devoted by the surgeon to learn the exact 
amount of tension of the rubber required to just stop arterial circulation. 

The band should never be applied before the patient is relaxed, and it 
should not remain on longer than absolutely necessary. 

Note. — The rubber constrictor exerts an enormous amount of constant and un diminishing 
pressure, hence it must be used with discretion. Applying it to the thigh held in flexion may 
lead to rupture of all flexors if the limb is straightened out afterwai-d. 

For a number of years, the author has discarded all specially made 
bands and apparatus recommended by authors and sold by dealers for the 
production of artificial anaemia. 

A piece of pure gum-elastic tubing, of the thickness of a man's index- 
finger or thumb, and of the length of one and a quarter yard, is all that is 
necessary. Its application is illustrated in Fig. 56. The limb being held 
vertically for a few minutes, the elastic tube is put on the stretch, and thus 
coiled about the limb once or twice, its tension and the number of turns 
being determined by the relative thickness of the limb, the muscularity, 
and amount of adipose tissue underlying the skin. To estimate the tension 



68 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




required, the feel of the radial and dorsalis pedis arteries may serve respect- 
ively. As soon as their pulsation disappears, the constriction is sufficient. 

When the required 
amount of constriction 
is secured, the ends of 
the tube are crossed, 
a short piece of cord 
or muslin bandage is 
passed under the cross- 
ing, and is firmly tied 
in a slip-knot. The 
ends of the tube being 
released, the rubber 
crowds up against the 
cord, and can not slip. 
(Fig. 57.) 

This mode of con- 
striction is very ener- 
getic, and deserves the 
preference for very 
large and muscular ex- 
tremities. 

Another practical 
and more gentle ivay 
of applying elastic constriction is by means of an ordinary pure gum roller 
or Martin's elastic bandage. It is especially suited for emaciated limbs and 
for operations on wo- 
men of delicate frame, 
and children. 

The manner of ap- 
plying Martin's band- 
age is well illustrated 
in the accompanying 
cuts. As many turns 
of the bandage are 
superimposed tightly^ 
around the limb as 
necessary. The last 
turn is grasped in 
the left hand, and is 
pulled away forcibly 
from the limb, form- 
ing a bight, into which 
is thrust the remain- 
der of the roller. As soon as the left hand releases the loop, it tightens 
about the roller, and holds it in place firmly and securely. (Fig. 58.) 



-Manner of applying elastic constrictor (rubber tube) 
for the production of artificial anaemia. 




Fig. 57. — Elastic constrictor in situ. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



69 



I. Ligatuees and Final H^mostasis. — The visible lumina of all cut 
vessels — veins and arteries — are tied with catgut, which is in every way pref- 
erable to silk. The objections raised against the new material have been 
entirely disproved by experience. The author never saw one case of sec- 
ondary haemorrhage from a vessel tied with catgut ; and knows of two cases 
only, quoted on pages 5 and 56 respectively, where catgut ligatures slipped 
or gave way. In both, very brittle catgut was used, and the knot was not 
sufficiently tightened on account of the fear of breakage. Therefore it may 
be said that improper 
material was improperly 
applied in both of these 
instances. 

In tying larger ves- 
sels it is very necessary 
to grasp and withdraw 
them from their sheaths 
for inspection. 

Arteries will some- 
times be laterally nicked 
just a little above the 
transverse section, and 
the ligature must be ap- 
plied above the lateral 
opening. 

Large veins must be 
also well inspected, as 
it may happen that the 

lumen of a hastily tied vein may be only partially occluded by the ligature. 
An ordinary artery forceps can not grasp at once the entire circumference 
of a principal vein, and the author has repeatedly seen only one half of the 
vein deligated in the shape of a dog's ear, the remainder of the vein con- 





Fig. 58. — a. Applying of Martin's bandage as a constrictor. 
^/Martin's bandage in situ. 




Fig. 59.— The wrong way of detaching the skin-flap. The knife should be held vertically. 



tinuing to bleed in spite of the ligature. The best way to secure the entire 
lumen of a large vein is to grasp and withdraw it with one or two forceps 
11 



70 



EULES OF ASEPTIC AND ANTISEPTIC SUEGEEY. 




Fig. 60. — Liston's bone forceps. 



until its whole circumference is clearly visible, and then to twist it around 

its own axis, when it will be seen to form a neck which can be easily tied. 
Atheromatosis of arteries is no valid objection to the application of the 

catgut ligature. 

The grasping of 

vessels affected 

by it is difficult 

on account of 

their liability to 

slip before, and 

break after, be- 
ing caught by the forceps. The ligature must not be tightened too much 

on an atheromatous vessel, or it may cut through it. 

Vessels imbedded in sclerosed tissues must be secured by a circular stitch. 
After the removal of the elastic constrictor, local comjDression of the 

wound is kept up until the marked hypersemia of the limb begins to wane. 

Then, an assistant compressing the main artery, the wound is exposed. The 

glazing of clotted blood is re- 
moved by irrigation and gentle 
friction with the tips of the 
fingers, and the assistant is di- 
rected to release the compressed 
main artery. Then any addition- 
al vessels seen spurting should 
be secured. The hyperemia of 
the limb will have ceased by 
this time, and with it the ooz- 



: 

f 




mg. 

Note. — Should a larger nutrient ar- 
tery be divided at the time of the sec- 
tion of the bone, its bleeding can be 
readily stopped by the insertion of a 
short piece of stout catgut into the 
spurting orifice, where it can be left be- 
hind without any harm. The employ- 
ment of wax for the same purpose is 
unsafe, unless the material is first ster- 
ilized by boiling. 



Fig. 61. — Amputation wound of thigh, 
drained. 



ait u red and 



The statement that Es- 
march's apparatus is not blood- 
saving, but, on the contrary, 
causes undue haemorrhage, is misleading. It may be positively said that 
skillful management of the application of Esmarch's constrictor will enable 
the surgeon to perform major operations with an astonishingly small amount 
of haemorrhage, and that loss of much blood after the removal of the rubber 
band is due to faulty manipulation. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



71 



3. Securing of a Good Stump. — In circular amputations, as well as in 
flap operations, an important object should be to gain abundant covering, 
and to bring about easy and natural apposition of the wound-surfaces with- 
out much external 
pressure. 

In performing cir- 
cular amputation, the 
assistant holding the 
mesial part of the 
limb can greatly in- 
fluence the shape of 
the stump. As it is 
desirable to produce 
a wound of the shape 
of a hollow cone, 
multiple circular sec- 
tions of not too great 
depth are commend- 
able, while the assist- 
ant successively re- 
tracts each layer divided by the amputating knife until the periosteum is 
cut through and pushed well back. The soft parts are inclosed in a two- 
or three-tailed compress of sublimated gauze, and the bone or bones are 
sawed off, care being taken on the leg and forearm to complete the sec- 
tion of both bones simul- 
taneously. After this the 
sharp edges of the bone 
are clipped off with bone- 
cutting forceps, and the 
vessels are attended to. 

Musculocutaneous flaps 
make a very good covering 




Fig. 62. 



-Amputation wound of leg, sutured and drained, 
tive plate sutures. 



Eeten- 



Fm. 63. 
Dressing of amputation 
wound of the thia:h. 




to most stumps, and can be very easily adapted. As soon as the haemor- 
rhage is perfectly under control, suture of the wound can be commenced. 



72 



EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



The author is using exclusively the interrupted suture, for reasons elsewhere 
mentioned. 

If the case was unimpeachably aseptic, and no suppuration is expected, 
one medium-sized drainage-tube will suffice to carry away the first secre- 
tions. Otherwise abundant ways of egress must 
be provided in the shape of several properly dis- 
tributed tubes. The protruding end of each tube 
is transfixed with a safety-pin, and cut off on a 
level with the skin. An ample dry dressing, con- 
sisting of a few layers of iodoformed and a gen- 
erous mass of sublimated gauze is 
snugly bandaged to the stump, so as 
to reach at least twelve inches above 
the line of section. 

If proper care was devoted to the 
stanching of the haemorrhage, no great 
pressure will be required to check the 




oozing, which is, anyway, moderate 



Fig. 64. — Dressing of amputation wound of 
the leg. 



9L after the use of corrosive sublimate 

^ ^y^ 1~~ . J ~ ^HJBPj?t f° r irrigation 

The idea of bringing about close 
apposition of the wound-surfaces by 
energetic pressure is not to be culti- 
vated, as it will lead to frequent marginal necrosis of the flaps, frustrating 
complete primary union. Surface apposition should rather be accomplished 
by a proper fashioning of the wound and flaps, 
and the sutures should exert no traction what- 
ever, but should merely secure contact of the 
cutaneous edges. 

For securing contact of the deeper portions 
of an amputation wound, Lister's lead-plate sut- 
ures are very advantageous. (Fig. 62. ) 

Note. — In former times, when car- 
bolic lotions were employed for irriga- 
tion, oozing used to be quite free, and 
necessitated the use of a good deal of 
pressure, which was somewhat tempered 
by the interposition of thick layers of 
borated cotton between the dressing 
proper and the outer bandage. Flap 
necroses were then much more com- 
mon than nowadays. 

The sole office of the dress- 
ings is to lightly support the 
wound, and to absorb and ren- 

... Fig. 65. — Amputation wound of the thigh fourteen 

der innOCUOUS the Secretions. days after the operation. Case of Mrs. Walther. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



73 



The author's custom is to make the, first change of dressings about a 
fortnight after the operation, when the drainage-tubes can be withdrawn. 
Another lighter aseptic dressing is then applied, and remains undisturbed 
for a week. By the end of this time the drainage-tracks will have either 
healed completely, or their place will be marked by a small patch of granu- 
lations, requiring merely a borated-salve or simple adhesive-plaster covering. 

This refers to correct cases only. Should septic fever develop or mar- 
ginal gangrene be noted, frequent moist dressings are in order, and the rules 
appropriate for the treatment of suppurating wounds obtain precedence. 

Case: Illustrating a Correct Course of Healing. — Mrs. Pauline TValther, seam- 
stress, aged fifty-one. Far-gone tuberculous destruction of knee-joint with fistula, the 
latter the result of a previous exploratory incision. Feb. lJ^th. — Amputation of thigh 
in middle third. Aseptic fever, with rise of temperature to 103° Fahr., on the two days 
following the operation. Feb. 18th. — Temperature, 99° Fahr. March 1st. — First 
change of dressings; drainage-tubes removed ; wound redressed. March 7th. — Wound 
completely healed, except where one minute spot of granulations marks the former site 
of a tube. March 12th. — All firmly cicatrized; the stump can be lightly pounded 
without pain. March 17th. — Patient discharged cured. See Figs. 61 and 65. 



IV. OPERATIONS ABOUT NON-SUPPURATING JOINTS. 

1. Puncture and Irrigation. — Chronic hydrops, or, as Volkmann calls 
it, catarrhal synovitis of the knee-joint, is often benefited or even cured 
by puncture and subsequent irrigation. 

Schede's rule of using corrosive sublimate (1 : 1,000) 
whenever the synovial fluid is turbid, and carbolic 
lotion (three per cent) when it is clear, can be com- 
mended as rational. In the former case pyogenic 
elements cause the production of a certain amount of 
[ycocythes, and hence the use of a strong germicide 
like corrosive sublimate is appropriate. 
Simple hydrops, where there is no ad- 
mixture of pus-cells, is comparable to 
bursal hydrops or hydrocele, and is 
benefited by the ap- 
plication of an irri- 
tant substance like 
carbolic acid. 

The manner of 
procedure employed 
by the author is as 
follows : 

Two large - cali- 
bered trocars are ren- 
dered aseptic either 
by boiling the tubes for an hour in a five-per-cent solution of carbolic acid, 
or by heating them in a large alcohol flame to incandescence, after which 




Fig. 6$. — Irrigation of knee-joint. 



74 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

they are dropped into carbolic lotion. Too much care can never be exer- 
cised in attending to the proper disinfection of the trocar-tubes, as their 
hollow shape renders their cleansing a difficult matter at best. 

Case. — Thomas Casey, hostler, aged twenty-three. Hydrops of right knee-joint 
of several years' standing. March 11/,, 1887. — Puncture and irrigation with Thiersch's 
solution and carbolic lotion. Dorsal splint. The trocars had received a rather super- 
ficial attention by boiling of too short duration. The following day high fever appeared 
with great distention of the joint. March 15th. — Aspiration yielded pus. March 16th. 
— Multiple incision and drainage. The fever not abating, although secretion was very- 
scanty, the limb was suspended in a wire cradle, and weight extension was applied, so 
as to enable the house-surgeon to frequently irrigate the joint without disturbing the 
patient's rest. In spite of the most attentive treatment, new abscesses developed, and 
the patient's evident failing finally compelled amputation of the thigh, which was done, 
May 30th, by Dr. F. Lange. The patient recovered. Extensive tuberculosis of the head 
and shaft of the tibia was ascertained by examining the specimen. 

After the usual preparation of the patient's limb, the trocars are thrust 
into the knee-joint from opposite sides, and the synovial fluid is let out. 

To remove flocculae of coagulated fibrin, Thiersch's solution is first used 
for washing out the joint cavity. The reason for this is the fact that car- 
bolic acid hardens the fibrinous clots and makes them tough and unfit to 
pass the cannula. Corrosive sublimate, on the other hand, is poisonous, 
and dangerous quantities of it may be absorbed if irrigation be carried on 
sufficiently long to free the joint of all deposits of fibrin. 

Case.— John Schurz, mason, aged thirty, chronic hydrops of knee-joint. April 8, 
1886.— At the German Hospital, double puncture and rather prolonged irrigation with 
corrosive- sublimate lotion (1 : 1,000) on account of the presence of large quantities of 
fibrinous deposit. April 10th. —Mercurialism ; salivation and sharp colic, lasting for five 
days, with some fever, ending in recovery on appropriate treatment. Hydrops cured. 

As soon as Thiersch's fluid is seen to escape clear from 
the efferent cannula, corrosive sublimate or carbolic lotion 
is substituted therefor, and the joint is thoroughly flushed 
with it. To prevent the retention of a dangerous amount 
of either of these solutions, the joint is flexed and emptied 




Fig. 67.— Volkman's T-splint. 



by external pressure. The tubes are withdrawn, a small patch of iodoform 
gauze is attached with a strip of adhesive plaster over each puncture-hole, 
and the limb is placed on a dorsal splint. (Fig. 67.) 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 75 

2. Arthrotomy for Chronic Fibrinous Hydrops, for Vegetations, Tumors, 
and Floating Bodies of the Knee-joint, a. Hydeops Genu. — In cases 
where a thick coating of fibrinous deposit is lining the entire cavity of the 
knee-joint, simple puncture and irrigation will be found impracticable on 
account of the continuous clogging of the efferent cannula. To completely 
free the joint of these masses, immediate incision must be done. The in- 
ternal aspect of the knee presents the most convenient place for this pro- 
cedure. The skin and fascia are successively incised, and all bleeding vessels 
are carefully tied. On being exposed, the bluish capsule is cut into, and 
the incision is extended to about an inch in length. After this, irrigation 
by Thiersch's solution is practiced, and the joint is repeatedly flexed and 
extended to aid detachment and expulsion of the membrane, which can be 
hastened by sweeping the index-finger through all the recesses of the joint. 
The slight haemorrhage following this manipulation will cease spontane- 
ously, and the clots are washed out by a strong jet of irrigating fluid. 




Fig. 68. — Arrangement of rubber sbeets for operations about the lower extremity. 

After the insertion of a short piece of medium-sized drainage-tube, which 
should reach just within the cavity of the joint, the capsular incision is 
closed by a few interrupted catgut sutures. 

The fascia and skin are likewise united, the protruding end of the tube 
is transfixed with a safety-pin and trimmed off short, and the joint receives a 
final flushing with carbolic or mercurial lotion according to the indications 
mentioned in the preceding paragraph. 

After this the wound is dressed and the limb is fixed upon a dorsal splint. 

If the aseptic measures were sufficient, no reaction whatever will follow 
the operation. In cases where the hydropic fluid was limpid, no secretion 
of any account will be observed, and the tubes can be withdrawn at the first 
change of dressings, which is usually done on the fifth day after the opera- 
tion. As soon as the wound is in progress of cicatrization, active movements 
and cautious use of the limb should commence, the joint being protected 
by a small aseptic dressing, held in place by Martin's elastic bandage. 

Case of John Sclmrz, page 74, who was discharged cured June 29, 1886, with 
partially restored and constantly improving mobility. 

Passive movements are unnecessary and very painful. Restoration of 
the mobility should be hastened by cold or warm douching and subsequent 



76 KULES OF ASEPTIC AND ANTISEPTIC SURCEKY. 

massage, and its final establishment left to the active efforts of the patient 
himself. 

Cases in which large quantities of firmly adherent membrane were 
removed and some haemorrhage followed, especially if the hydropic fluid 
was very turbid, will develop a moderate secretion of serous bland pus, that 
may continue for some time. Some fever will also occur, to subside as soon 
as the dressings are changed and the joint is washed out again. 

It will commend itself to apply in these cases a fenestrated plaster-of- 
Paris splint, and to repeat irrigation once or twice daily in the beginning, 
diminishing the number of washings pari passu with the disappearance of 
the secretion. As soon as the discharge shall have become serous and 
scanty, the tube can be withdrawn and the case treated as above explained. 

Case. — Fred. Schecker, laborer, aged twenty-six, had been suffering for several 
years from a painless, massive, hydropic distention of the right knee-joint, that could 
not be traced to a traumatism. Considerable lateral mobility was the main cause of his 
seeking relief at Mount Sinai Hospital. Dec. 7, 1885. — Double puncture and irriga- 
tion were done, but had to be abandoned on account of large masses of dense fibrin. 
Immediate incision and clearing of the joint were practiced. Fever and some secretion 
being noted, the dressings were changed December 10th, and, the limb being put up in 
a fenestrated plaster splint, irrigation with corrosive sublimate was employed twice — 
later on, once — daily. Dec. 20th. — Normal temperature was noted. Feb. 1st. — Irriga- 
tion discontinued and splint removed. Feb. 20th. — Patient discharged cured, with 
increasing flexion (twenty degrees). 

I. Vegetations. — The favorite seat of vegetations in the knee-joint is 
that lax part of the capsule situated below the inferior margin of the patella, 
which is overlaid by a thick cushion of loose fat and the ligamentum 
patellae proprium. They are rarely pedunculated, their common appear- 
ance being that of a yellowish or purple coxcomb, and their direction trans- 
verse. The functional disturbance produced by them is sometimes very 
slight, but occasionally extremely severe, especially when it happens that 
their margin is caught and jammed in between the articular surfaces. 
Haemorrhage with acute synovitis and an effusion may follow this accident. 

The diagnosis of vegetations, sufficiently massive to cause functional 
trouble, is not difficult to the careful examiner. Frequently the patients 
themselves will point out the kernel-like slipping bodies of soft consistency. 
They are easily distinguished from free floating bodies by the fact that on 
manipulation they never disappear entirely from their seat of predilection, 
to reappear in a distant part of the joint. 

Topical treatment is generally powerless against this complaint, 
although the constant use of a Martin's bandage may mitigate the trouble 
by confining somewhat the motion of the joint, and thereby diminishing the 
chances of contusion of the growths by jamming. 

In aggravated forms, arthrotomy and excision of the vegetations is 
proper. With strict attention to the cautelae before mentioned, the joint is 
incised, and, the patella being tilted upward by a sharp retractor, the mass 
is grasped with a pair of mouse-tooth forceps, and is bodily excised. Should 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 77 

it extend across the entire width of the patella, another lateral incision will 
have to be made on the opposite aspect of the knee, to enable the surgeon 
to complete the excision. 

If much hyperemia of the growth be present, as shown by its purplish 
color, haemorrhage may be rather free. In such a contingency the raw sur- 
face should be seared with the thermo-cautery. 

Toilet of the joint cavity is followed by suture, and a small drainage- 
tube is inserted to serve as a safety-valve. The subsequent treatment coin- 
cides with that given for simple hydrops after puncture and irrigation. 

Case 1. — Miss Lena C, aged fourteen, vegetations occupying the internal inferior 
margin of the patella. The patient had frequent attacks of sudden, very sharp pain 
in the knee, followed by effusion. Various plans of local treatment had been em- 
ployed unsuccessfully for about a year. Dec. 5, 1881. — With the assistance of Dr. B. 
Scharlau, the family attendant, incision 01 knee-joint on its inner aspect was done. 
A series of yellow, smooth bodies presenting, they were excised with forceps and 
curved scissors. Drainage, suture, and plaster- of-Paris splint. Some fever, due to 
constipation, but no inflammation followed. Dec. 9th. — A laxative being administered, 
a copious stool was had, whereupon the temperature at once fell to, and remained at 
the normal standard. Dec. 12th. — The tube was removed. About New Year's the 
patient commenced to walk about, and shortly after was discharged cured. In the 
spring of 1886 circumscribed swelling of the synovial membrane in the vicinity of the 
cicatrix was noted. It subsided upon the use of an elastic bandage, which was ulti- 
mately abandoned. In January of 1887 the patient was still perfectly well. 

Case 2. — Frank Mann, clerk, aged twenty-five, well-defined painful vegetations 
to be felt near the lower margin of the knee-pan, on both sides. Duration of trouble, 
six months. Functional disturbance very marked. April 8, 1886. — Double incision 
of knee-joint at the German Hospital. Excision of a deep-red, transversely situated, 
coxcomb-like growth from the lower rim of the patella. A good deal of oozing neces- 
sitated searing of the denuded surface of the capsule with the thermo-cautery. Drain- 
age; plaster-of- Paris splint. Eventless course of healing. The tube was removed on 
the tenth day. Patient discharged cured, with good motion, May 20, 1886. 

c. Floating Bodies of the Kkee-Joixt : 

Case. — E. Behrmann, painter, aged thirty-eight. Large floating body of the knee- 
joint, with chronic hydrops. May 15, 1886. — Arthrotomy at the German Hospital. 
Previous to the incision the floating body was fixed by finger-pressure near the line of 
section, but disappeared in the joint cavity when the last stroke of the knife opened 
the capsule. The author swept through the joint with a well-rinsed finger, and found 
the body in the bursa of the quadriceps muscle. By means of bimanual manipulation, 
the body was brought down to the aperture, and was readily extracted. Irrigatiou 
with corrosive-sublimate lotion, drainage, suture, and fixation upon a dorsal splint fol- 
lowed the extraction. Normal course of healing. June 15, 1886. — The patient was 
discharged cured with good function of the knee. 

d. Sutuuikg oe the Fractured Patella. —Although not perfect, 
yet the functional results achieved by the ordinary forms of treatment em- 
ployed in cases of transverse fracture of the patella are generally so good, 
that arthrotomy, for the sake of wiring or otherwise suturing the patellary 
fragments, is rarely if ever justified at a time immediately following the 

12 



78 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

injury. Hamilton has shown that even a considerable degree of diastasis 
of the fragments is not incompatible with a very fair functional ability of 
the limb, provided that the intervening ligamentous band be strong, the 
action of the quadriceps vigorous, and the lateral extensions of the quadri- 
ceps tendon uninjured. 

It seems, then, rational, in cases of patellary fractures, first to employ 
the usual methods of treatment by rest and appropriate bandaging, and thus 
to await the result. It never can be predicted with accuracy, and may turn 
out to be very satisfactory after all. 

Should the result be unsatisfactory, either through failure of union or 
subsequent rupture of the new-formed ligament, arthrotomy and secondary 
suture may properly be taken into consideration. 

On account of the presence of large quantities of blood and serum, found 
shortly after the accident elf used into the joint and its vicinity, primary 
arthrotomy for patellary fracture is a more risky undertaking than the sec- 
ondary operation. The slightest error in the use of the aseptic apparatus 
may cause irreparable damage, and may cost the patient's limb or life. 
Especially dangerous are those cases in which open ulcers or abrasions, or 
other secreting wound-surfaces due to the primary injury, are located near 
the field of operation, be they however small or superficial. Pyogenic in- 
fection and suppuration of the knee-joint are here nigh to inevitable. 
Anchylosis is the most favorable issue that can be expected in case of sup- 
puration ; very often, however, the limb will have to be sacrificed. 

The conditions for the successful performance of the secondary opera- 
tion are, as far as the chance of avoiding suppuration is concerned, infinitely 
better. The effusions due to recent traumatism are mostly absorbed, the 
parts have recovered their physiological equilibrium, and faults of aseptic 
technique are easier to avoid and not as hard to remedy as in recent cases. 

The circumstance can not be urged as a serious drawback, that a few 
weeks after the accident, the fracture-planes are found covered with new- 
formed connective tissue or a cicatrix, and that this must be first removed 
before suture can be applied. 

More difficulty may be encountered in overcoming the retraction of the 
quadriceps. But even such high degrees of retraction as are occasionally 
observed in complete failure of union, or met with in old secondary rupture, 
representing a diastasis of several inches, can be managed so as to permit 
suture and bony union of the fragments. 

The mode of procedure is well illustrated by the following history : 

Case. — Mrs. Lizzie P., housewife, aged twenty-eight, an extremely obese woman, 
contracted in 1884 a transverse fracture of the left patella, which was attended to by 
her family physician, and was treated by rest and bandaging. It healed with a seem- 
ingly satisfactory ligamentous union, which, however, gave way a few weeks after 
the completion of the treatment, resulting in a wide gap between the fragments. Meas- 
urement gave a hiatus of two and a half inches in extension, five inches in flexion at a 
right angle. Her gait was rather uncertain, causing many falls, one of which produced, 
May 2, 1887, a transverse fracture of the right patella. This recent fracture was treated 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 79 

by approximation with two broad strips of adhesive plaster, bandaged on and laced, 
the limb resting on a T-splirt. May 25th. — The old patellary fracture was united by 
operation at the German Hospital. The limb having been rendered ansemic by con- 
striction, the joint was laid open by a transverse incision, and the cicatricial tissue 
investing the fracture-planes of the knee-pan was cut away, and the bone scraped free 
from all adhering connective tissue, until the corresponding surfaces of the patella 
were clean and smooth. After this four equidistant holes were drilled through each 
fragment, while the bone under treatment was held immovably fixed by an assistant 
in the grasp of a lion-jaw forceps. The drilling of the apertures in the upper fragment 
was much easier than of those in the lower one. By the aid of a flexible silver probe, 
a double thread of thick catgut (No. 4) was drawn through the corresponding drill- 
holes, the ends of each suture being temporarily secured in the grip of an artery for- 
ceps. The most difficult part of the operation consisted in the approximation of the 
fragments. The quadriceps tendon was exposed by a longitudinal incision of six inches 
in length, and, the upper fragment being forcibly drawn downward with bone-forceps, 
a number of alternating lateral notches were cut into the muscle and tendon, until the 
fragment yielded to moderate traction. The first suture nearest the edge of the patella 
was tightened — not tied — by an assistant until the fragments were brought in contact, 
whereupon the second suture was firmly knotted. After this the fourth suture was 
tightened and the third one tied ; finally, the two outermost sutures were attended to. 
The ends of the catgut were trimmed, and three short drainage-tubes were inserted in 
the three angles of the wound. During the whole operation a stream of a 1 : 2,500 
solution of corrosive-sublimate lotion was played on the exposed tissues. Before the 
closure of the wound, it was finally flushed w r ith a 1 : 1,000 mercuric solution, and the 
application of a number of external catgut stitches completed the process. The knee 
was enveloped in an ample dry dressing and a pi aster-of -Paris splint, enforced by a 
few lateral strips of white-wood veneering. Finally, the constricting elastic band was 
removed, and the extremity suspended in the vertical position, which was abandoned 
twenty-four hours after the completion of the operation. June 3d. — Splint removed; 
dressings changed; drainage-tubes withdrawn. June 17th. — Wound healed through- 
out. Silicate splint applied. June 20th. — Patient commenced to walk on crutches. 
July 2d. — She was discharged cured. July 13th. — The union of sutured patella was 
found firm, the operated limb much more useful than its mate. Flexion could be car- 
ried to a right angle. The course of healing of the case was feverless throughout. 

3. Arthrotomy for Irreducible or Habitual Dislocation, and for Deformity 
due to Fracture. — Dislocations that are irreducible from the outset, or have 
become so through neglect, can be corrected by means of aseptic ar- 
throtomy. 

Case I. — Henry Kohler, aged nine. Dislocation of basal phalanx of thumb upon 
dorsum of metacarpal bone, of six weeks' standing. December 29, 1879. — Repeated 
unsuccessful attempts at reduction under chloroform. Immediate arthrotomy. Dis- 
section of abnormal adhesions, and excision of a shred of interposed capsular tissue, 
followed by ready reduction. Suture and catgut 
drainage. Primary union. Jan. 10th. — Patient 
discharged cured with improving function. 

Case II. — John Becker, aged twelve. Fresh 

compound dislocation of terminal phalanx of the 

ring-finger on the dorsum of the middle phalanx. 

i r 7 an -tooi -it^i j • • j. i l j.i Fig. 69. — Explaining relation of parts 

March 29, 1884.— Ether was administered at the in John Becker's case of phalangeal 

German Hospital, and, after careful disinfection dislocation. 




80 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 70. — Arrangement of rubber sheets for operations 
about the upper extremity. 



of the patient's hand, reduction was repeatedly attempted without success. The small 
transverse laceration of the integument of the volar aspect of the finger did not give 
the least advantage as to examining the interior relations of the displacement, hence a 
lateral incision was made on the radial side. It was then ascertained that the tendon 
of the flexor digiti profundus was displaced upon the dorsum of the middle phalanx, and 

was interposed between the ar- 
ticulating surfaces. An addi- 
tional lateral incision on the 
opposite side of the finger was 
necessary, and reduction could 
only be accomplished after a 
free division of all resisting 
bands of torn capsular ligament, 
caught between the flexor ten- 
don and the articulating surfaces 
respectively. Suture and catgut 
drainage ; fixation of the finger 
on a small volar splint. April 
5th. — First change of dressings. 
Primary union. In May the 
function of the injured joint be- 
came nearly normal. (Fig. 69.) 
Case III. — Joseph Jeretzky, aged eight. Old, irreducible dislocation of basal pha- 
lanx of index upon the dorsum of the metacarpus. May 19 1 188^. — Lateral incision. 
Division of the new-formed cicatricial bands ; removal of an interposed shred of the 
capsular ligament. Reduction and primary union with perfect restoration of function. 

Condylar fractures of the elbow ivith posterior or lateral displacement 
of the forearm are a common injury with children. What with the great 
difficulty of an exact diagno- 
sis in the presence of a large 
effusion, and the great differ- 
ences of opinion of the au- 
thors as regards the proper 
manner of treatment, no won- 
der that, after elbow-fract- 
ures, cases of gun-stock de- 
formity and partial disloca- 
tion with inability to flex the 
elbow are not at all rare. 
Some of the authors advise 
putting up of the fracture in 
extension, others in flexion ; 
some recommend early pass- 
ive motion with frequent change of the angle of the elbow ; others condemn 
altogether early passive motion. 

The author's conviction is that in many instances exact reposition and 
retention are utterly impossible unless the fragment is cut down upon and 
sutured or nailed to its original seat. The insertions of the muscles of the 




Fig. 71.— Dress 



for wounds of hand and forearm. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



81 



forearm about the epicondyles must exert a great influence upon the dis- 
placement of the fragments, hence it seems that flexion would be the better 
position to counteract the tendency to displacement. But all assertions 
made to that effect, that, in spite of the presence of a large swelling, reduc- 





erior view of guD-stock deformity due to elbow fracture. 



tion can always be accomplished and retention maintained, have appeared 
to the author as a hollow pretense or self-deception. 

A very guarded prognosis in elbow-fractures is, on the part of the physi- 
cian, a sign of wisdom and discretion. 

Where very limited motion and an unfavorable position result in spite 

of careful treatment, the only means of 
correction is arthrotomy with subsequent 
partial or total exsection. 



Fig. 73.— Lateral view of Bernhard 
Loebel's elbow. 




Fig. 74. — Normal aspect of lower end of hume- 
rus, a a. Transverse diameter, b b. Line of 
fracture. In Bernhard Loebel's case. 



Case I. — Bernhard Loebel, aged two. October 27, 1886, injured bis elbow by fall- 
ing off a chair. The arm was put up by a physician in the flexed position in plaster 




Fig. 75. — Showing relative positions of frag- 
ments in Bernhard Loebel's cass. 




Fig. 76. — Anterior view of 
lower end of humerus in 
Bernhard Loebel's case. 



of Paris, and remained in this dressing for a fortnight. Dec. 7, 1886. — The elbow- 
joint showed very marked gun-stock deformity. It was held at an angle of about 



82 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



one hundred and forty degrees. Flexion could be carried to about one hundred and 
ten degrees; extension not beyond the angle first mentioned. The forearm was dis- 
placed inward and backward, and the tendon of the triceps described a well-pro- 
nounced concave line. An abnormal mass of bone could be felt in the bend of the 
elbow externally, behind and below which the head of the radius could be made out 
with some difficulty. A posterior incision midway between the abnormal mass of 
bone and the olecranon opened the joint, and the periosteum was raised by means of 
the knife and elevator on both sides of the incision until the lower end of the humerus 
could be turned out for inspection. It was found that the deformed callus consisted of 
the external epicondyle, capitellum, and a small portion of the trochlea that had been 
broken otf obliquely, and was tilted and pulled forward by the action of the flexors so 
as to present its articular aspect forward, part of the fractured surface looking back- 
ward. In this position bony union had taken place. The elongation of the outer half 
of the articular end of the humerus accounted for the gun-stock deformity ; the pres- 
ence of the large mass of bone dis- 
placed forward by tilting of the frag- 
ment explained the inability to flex. 
The lower end of the humerus was 
pared off horizontally with the knife, 
care being taken to remove a little 
more from the external than from 
the inner half of the lower end of 
the humerus, in order to preserve 
the "carrying point." The capsule 
and skin were united by suture. 
One drainage - tube was inserted. 
The arm was put up in extension in 
a couple of lateral pasteboard splints. 
No fever followed. Dec. 14th. — First 
change of dressings. In anaesthesia 
the tube was removed, and the arm 
was flexed to an acute angle and put 
up in this position in two lateral 
pasteboard splints. Dec. 19th. — Pas- 
sive motion was practiced in anaes- 
thesia, and the arm was fixed in the 
straight position. Dec. 23d. — Passive 
motion without ether. Fixation at 
an acute angle. Dec. 29th. — Free 
passive motion to normal limits. 
Splints abandoned and active move- 
ments commenced. March 3d. — 
Outline of elbow almost normal. 
Flexion and extension normal. 

Case II. — Willie Her, aged elev- 
en. Yery pronounced gun-stock de- 
formity due to fracture of the elbow- 
joint sustained two and a half years 
ago. The treatment had been conducted by a surgeon of good repute. Flexion could 
be carried to a right angle, extension to about one hundred and thirty degrees. Fig. 
77 shows the boy's arm in full extension. June 17, 1887. — Arthrotomy done at Mount 




Fig. 77. — Gun-stock deformity due to T-fracture of 
the lower end of the humerus. Willie Her's case. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



83 



Sinai Hospital revealed a very curious condition of things. The broken-off external 
condyle and capitelluin occupied a position similar to that observed in the preceding 
case. The ulna was dislocated backward and 
inward from the fragment representing the tro- 
chlea, which was attached by callus to the an- 
terior aspect of the lower end of the humerus. 
Apparently a T-shaped fracture of the lower 
end of the humerus had taken place. The ar- 
ticular surface had a most grotesque shape. The 
cartilaginous surfaces of the trochlea and sig- 
moid incisure were coated with a dense mass 
of connective tissue. The broken-off coracoid 
process was attached to the fragment of the 
trochlea. The articular surface was pared off 
to approximate the shape of a normal hume- 
rus, and the wound was drained, sutured, and 
the arm put up in a pasteboard splint. Normal 
union by primary adhesion of the wound took 
place, but an annoying complication, consisting 
of paralysis of the forearm and hand, was noted. 
This untoward event was probably caused by 
the fact that the pad of Martin's bandage, used 
for producing artificial anaemia, had been placed 
over the inner aspect of the arm, exerting undue 
pressure over the nerves. June 19th. — The 
compressive dressings were removed, the drain- 
age-tube was withdrawn, and the wound re- 
dressed. July 2d. — The patient was discharged 
from the hospital with healed wound. Local 
treatment of paralvsis by galvanism and mas- 
sage was commenced. July 22d. — Flexion and 
extension of forearm and fingers re-established 
coming normal. Aug. 19th 




Fig. 78. — Besult after exsection of elbow- 
joint for gun-stock deformity. Willie 
Her's case. 



Aug. 1st. — Function of elbow be- 
-Muscular power fully restored. (See Fig. 78.) 

Habitual luxation of the shoulder -joint, a yery annexing and rebellious 
complaint, may also be cured by arthrotomy and partial exsection of the 
redundant capsular ligament. (See case on page 8, Note 2.) 



V. OPERATIONS FOR DEFORMITIES. 



1. Knock-Knee and Bow-Leg. — Operative exposure of the medullary tissue 
of the long bones is a dangerous procedure unless suppuration can be ex- 
cluded from the wound. By the successful employment of the aseptic 
method the danger of osteomyelitis can be virtually excluded. 

McEwen's osteotomy is one of the safest and most useful procedures of the 
newer surgery. It has almost entirely displaced purely orthopedic methods. 

For knock-knee, after division of the soft parts by a short longitudinal 
incision, the cancellous tissue of the lower end of the femur is divided by 
a properly shaped chisel, called osteotome. For bow-leg, the osteal section 
is carried through the upper end of the shaft of the tibia and fibula. The 



84 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



operation is done under artificial anaemia ; and the dressings are applied, and 
the limb is put up in a contentive dressing — preferably plaster of Paris — 
before the removal of the constricting elastic band. New-formed bone is 
thrown out into the gap caused by the correction of the position of the bones, 
and by the end of three or four weeks firm union in a normal position is 
the result. 

Case. — Leopold Heymann, clerk, aged nineteen. Very marked bow-legs, the dis- 
tance between the internal condyles of the femora being three and a half inches. No- 
vember 15, 1883. — Double osteotomy of the thighs at Mount Sinai Hospital. Plaster- 
of-Paris splints. Dec. ll^th. — Change of dressings. Wounds healed by primary union ; 
bones firmly consolidated. The knees were in contact, but the curvature of the tibise, 
which represented a great part of the deformity, was still very marked. Undoubtedly 
osteotomy of the shin-bones would have given a better result. The patient declined 
further operative interference. 

2. Bony Anchylosis in a vicious 
position. 

Case I. — Lina Frieberger, aged fif- 
teen. Bony anchylosis of right and pseud- 
anchylosis of left maxillary joint, prob- 
ably due to acute osteomyelitis of right 
ascending ramus. The teeth were in ab- 
solute apposition, and no solid food could 
be taken. Marked facial hemiatrophy. 
In childhood a suppurating affection of 
the right cheek was noted. April 3, 
1886. — Exsection by chisel and mallet of 
the left maxillary joint (hemiatrophy of 
the same side). 
The operation did 
not relieve the 
functional trou- 
ble ; the joint 
was found pseud- 
anchylosed, the 
cartilages gone, 
andthecapitellum 
nearly absorbed. 
The wound healed 
by primary inten- 
tion. April 29th. 
— Exsection of 
right maxillary 
joint, which was 
found firmly an- 
chylosed. The 

semilunar incision was obliterated, the capitellum, coronoid process, and temporal bone 
forming one solid mass. Immediately after its removal the teeth could be separated 
to the distance of an inch and a quarter. Primary union. Perfect restoration of func- 
tion noted in January, 1887. 



n 




Fig. 79. — Arrangement 
of nails in Maggie 
Scliweizers case. 



Fig. 80.— Final result in Maggie Schweizer's 
case. Cross-marks indicate places where 
nails were driven in. (Page 85.) 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



85 



Case II. — Maggie Schweizer, aged fifteen. 'Bony anchylosis of knee-joint at a right 
angle, in consequence of infantile acute osteomyelitis of tibia, with suppuration of knee- 
joint. January 22, 1886. — At the German Hospital, excision of the patella and of a 
wedge-shaped piece of bone, with preservation of the epiphyseal lines of femur and 
tibia. Transverse cutaneous incision, as for knee-joint exsection. Division of the 
bones by the saw, after peeling off of the periosteum. The sawed surfaces were brought 
together, and their fixation was secured by three steel nails, which were driven diag- 
onally through the tibia and femur in the horizontal plane — that is, from the lateral 
aspect of the extremity. The locking of the femur and tibia was so firm that the limb 
could be raised and handled like a solid staff. The application of the dressings was 
thereby made a very easy procedure. Full plaster-of- Paris splint. No reaction nnd no 
fever were observed. Feb. 23d. — First change of dressings. The nails and two drain- 
age-tubes inserted at the operation were removed. The bones were found firmly 
united. Over a small aseptic dressing a light silicate-of-soda splint was applied, and 
the patient was directed to walk on crutches. March 15th. — Discharged cured with 
light silicate splint. May 10th. — Presented herself to author, walking excellently with 
the aid of a raised sole. Shortening, two and a half inches. 

3. Deformed Callus. 

Case I. — William Paradies, laborer, aged thirty-eight. Deformed callus of the 
lower end of the tibia following a supra-malleolar fracture of the leg. Radiating pain 
issuing from the site of the deformity, due to pressure on the in- 
tegument, which was tightly stretched over the protruding edge 
of the upper fragment. March 7, 1887. — The deformed bone was 
exposed and chiseled away on a level with the surface of the dis- 
tal fragment. Suture ; no drainage. Primary u Dion. March 21st. 
— Patient discharged cured from the German Hospital. 

Case II. — Ernst Langer, carpenter, aged forty-five. Deformed 
callus of fibula. August 29, 1885. — At the German Hospital, in- 
cision and exsection of the callus by chisel and mallet. Apposi- 
tion and fixation of the fragments by a strong catgut bone-suture. 
Primary union. Discharged cured, September 26, 1885, with firm 
consolidation. 

4. Club-Foot and Pes Valgus. — On account of its sim- Fig. si.— Deformed 
plicity and the excellent results reported both from er end of tibia, 
abroad and at home after its practice, Phelps's operation dS 1 ) 1 ^ Para " 
seems to deserve extended trial. It consists in the com- 
bination of tenotomy of the tendo Achillis with a free division of all the 
soft tissues situated on the mesial side of the planta pedis, the incision 
penetrating down to the bone and, if necessary, into joints. The idea of 
dividing all resisting tissues underlies the plan of procedure. The incis- 
ion includes the tibialis anticus tendon, the tendons of the tibialis posticus, 
flexor digitorum communis longus, flexor hallucis longus, the belly of the 
flexor digitorum brevis, of the abductor hallucis, the plantar fascia, the long 
plantar ligament, the deltoid ligament, the nerves, and, if unavoidable, the 
vessels. The incision need not be a very long one. It commences just in front 
of the tip of the inner malleolus, and extends downward, according to the 
age of the patient, for about an inch or two. All the parts named above 

can be easily reached from the wound with a tenotomy knife, unless they 
13 




86 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

are in the direct line of section, when they are diyided with the scalpel. 
Preservation of the integrity of the plantar artery is very desirable, on 
account of the avoidance of saturation of the dressings with blood. The 




Pig. 82. — Group illustrating an operation about the foot or ankle. 

operation being done with the aid of Esmarch's band, all the tissues can 
be readily identified as they are gradually exposed step by step. The internal 
plantar artery can thus be seen and doubly tied. The main trunk of the 
artery sweeps in a long curve outward to the ex- 
ternal side of the sole, and is out of the line of sec- 
tion. Should it be divided accidentally, and the 
blood soil the dressings at once, it is proper to re- 
move them, to reapply Esmarch's band, to enlarge 
the incision, and to find and deli- 
gate the cut ends of the vessel. 
In extreme cases of adults, where 
the bones have acquired a definitely 
vicious shape, osteotomy or wedge- 
shaped excision of the neck of the 
astragalus must be added to the 
teno-myotomy performed in the 
pi ant a. 

The author was surprised to see 
the ease with which even great de- 
formities could be corrected after the division of all tissues mentioned above. 
Of course, the wound is a wide gap, which is widened still more by the cor- 
rected position. Its healing is accomplished by the organization of the 




Fig. 83. — Dressing for wounds of ankle and foot. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



87 




Fig. 84. 

Elevation of the feet 

after Phelps's operation. 



moist blood-clot (Schede's method). As soon as the wound has been well 
cleansed by irrigation, a piece of rubber tissue, previously kept immersed 
in a five-per-cent solution of carbolic acid for twenty-four hours, is placed 
over the gap. This is covered with a few strips of iodoform gauze and 
an ample dressing of sublimated gauze. While the foot is held in the cor- 
rect position 
by an assist- 
ant, the sur- 
geon applies 
over the asep- 
tic dressing 
a silicate-of- 
soda splint, 
and over this 
a plaster-of- 
Paris splint. 

While the plaster is setting, the 
foot is held with force in a 
somewhat overcorrected posi- 
tion, which will allow for the 
slight giving way of the asep- 
tic dressing. Then Esmarclrs 
band is removed, and the feet 
are held in the vertical posture 

for an hour or two after the operation. After disappearance of passive 
hyperemia they are placed on a pillow in the horizontal posture. 

In a fortnight or so the plaster-of-Paris shell is cut away ; the silicate 
splint thus exposed is finished off by a few turns of crinoline bandage soaked 
in silicate, and as soon as it is dry the patient is allowed to walk with the 
aid of crutches. In about four weeks after the operation the silicate shoe 
is split on top, and the dressings are removed. In many cases the wound 
will be found cicatrized over by this time. Should this not be the case, 
however, the aseptic dressing and silicate shoe must be reapplied. When 
the wound is perfectly healed, the silicate splint can be replaced by a well- 
fitting laced shoe. 

Note.— The silicate shoe must not include more than about one third of the leg, in order 
not to prevent treatment of its debilitated muscles by massage and electricity. 

The fear that the severed tissues will not grow together properly is un- 
founded. Schede had the opportunity of ascertaining by autopsy the exact 
re-establishment of the physiological relations of the cut tissues. The best 
proof of the fact is, however, the restoration of the function of the cut 
parts. 

The results exhibited by Phelps at a meeting of the New York State 
Medical Society at Albany surpass everything the author has seen accom- 
plished by any surgeon for the cure of this deformity. 



88 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Case.— Harry Epstein, school-boy, aged twelve, suffering from chronic interstitial 
nephritis as a consequence of scarlatina. General condition poor, on account of lack 
of exercise, due to disability from club-feet. The patient was walking on the outer 

edge of the plantar. The 
urine contained granular 
and hyaline casts, and 
twenty per cent of albu- 
men. March U, 1887.— 
At Mount Sinai Hospital, 
double Phelps's operation 
was done under chloro- 
form, which was borne 
excellently, the operation 
lasting forty-five minutes. 
No fever, no reaction 
followed. March 28th.— 
Trie plaster shell was cut 
away, and the patient 
commenced to hobble 
about in the ward on 
crutches. April 10th. — 
The old water-glass splints 
were removed, and were 
replaced by a new set, 
which were worn until 
June. After this the patient was fitted with a pair of lacing shoes. 

Case II. — Aaron Meyer, oysterman, aged twenty-nine, far gone and very painful 
pes valgus of both feet. Oct. 12, 1885.— At Mount Sinai Hospital, exsection of a bony 
wedge by chisel and mallet from the internal aspect of the head of the astragalus, 
the scaphoid, and calcaneum of the right foot. Area of the base of the wedge about 
one square inch. The remnants of the neck of the astragalus and calcaneum were 
divided entirely by the osteotome, and the foot was broken into shape by manual force 
and put up in an aseptic dressing and plaster-of-Paris splint. Nov. 1st. — Dressings 
removed, wound presenting a strip of shallow granulations. Dec. 1st. — Discharged 
cured. Feb. 1st. — Foulis's operation on the left foot, which showed a lesser degree of 
deformity than the right foot before operation. The talo-navicular joint was incised, 
and its entire cartilaginous covering was removed by scraping with a scoop. Feb. 21st. 
— First change of dressings ; primary union. Feb. 27th. — Patient discharged cured. 
In March, 1887, patient presented himself for examination. Firm anchylosis of the 
talo-navicular joints of both sides, and very good function had been secured, the 
patient attending to his accustomed business. 




Fig. 85. — Appearance of wounds four weeks after Phelps' 
operation. Harry Epstein's case. 



VI. PLASTIC OPERATIONS. 



Aseptics have greatly improved the results of plastic operations, and 
especially erysipelas has been almost entirely banished from facial wounds 
made for plastic purposes. In performing any operation about the face it 
is necessary for the surgeon to protect himself and the patient from two 
sources of infection. One is the oral and nasal secretions, the other the 
patient's head, notably his hair. The latter should always be enveloped in 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



89 




a cap extemporized from a good-sized towel or compress wrung out of cor- 
rosive-sublimate lotion. The accompanying illustrations show the manner 
of folding the towel about the head. It should be firmly fastened by a 

narrow roller-bandage encircling the forehead 
and occiput. Whenever vomiting occurs, a 
careful cleansing of the soiled skin and a 
change of towels are indicated. 

Where there is no great tension to be over- 
come, fine catgut (No. 0) makes excellent sut- 
uring material for facial wounds after plastic 
operations. 

Where the tension is great (which, how- 
ever, should be reduced to a minimum by the 

proper shaping of 
flaps and free dis- 
section), silver wire, 
or silkworm - gut 
well soaked in car- 
bolic lotion, will be 
well employed for 
retentive purposes. 
Sutures of coapta- 
tion are best made 
with fine catgut. 

Hare - lip pins 
were never used by 
the author, as they are unnecessary, and offer no advantages over the sutur- 
ing material more generally employed by surgeons. 

Where the wounded surfaces can be completely closed by suture, no 
dressings whatever are needed. A thick layer of iodoform dusted over the 
line of union will soon unite 
with the oozings into a paste, 
which on becoming dry will 
form an excellent and un- 
irritating protection to the 
wounds and suture-points. 
Daubs of collodion, or the 
application, after hare - lip 
operations, of strips of ad- 
hesive plaster to the face, 
are especially unpleasant and 
irritating to infants. They 
create uneasiness, and excite 

the little patients into crying fits, and the distortion of the face resulting 
from frequent crying is certainly not conducive to the uninterrupted rest 
and union of the wounds. 



.. 




Fig. 86. — Applying aseptic cap. First step. 




Fig. 87. — Applying aseptic cap. Second step. 



90 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




-Aseptic cap in situ. Cancer of lip. 



Retentive sutures should never be removed too soon — that is, before the 
seventh day. The smaller catgut sutures will be absorbed by that time. 

Where an uncovered de- 
fect is unavoidably left be- 
hind, on account of lack of 
integument or some other 
reason, Schede's procedure is 
the best means of preventing 
suppuration. A strip of rub- 
ber tissue is laid over the de- 
fect, and is suitably inclosed 
in an aseptic dressing. The 
blood-clot, which will form 
under the rubber tissue, will, 
if it be well protected from 
desiccation and decomposi- 
tion, rapidly become organ- 
ized. 
In plastic operations performed about the soft and hard palate the con- 
dition of the teeth should be well attended to previous to the undertaking. 
Decaying teeth should be removed, and an unwholesome state of the gums 
and mucous membrane should be 
corrected by the diligent use of the 
tooth-brush and a 1:1,000 solution 
of permanganate of potash as a 
mouth-wash. 

Urethroplasty will fail almost in- 
variably if ammoniacal urine is per- 
mitted to pass over the line of union. 
Acid urine is not deleterious to the 
wounds. Where chemical examina- 
tion has established the presence of 
ammoniacal decomposition of the 
urine, frequent washings of the blad- 
der and the urethra with weak so- 
lutions of permanganate of potash 
(1 : 4,000 or 5,000) and the internal 
administration of boracic acid will 
suitably prepare those organs for the 
operation. To prevent the soiling 
of the wound by ammoniacal urine, 
a soft Nelaton catheter should be 
passed into the bladder and fixed by 

a proper bandage to prevent its escape. Daily antiseptic irrigation of the 
bladder should be continued all the time while permanent catheterism is 
used. As soon as the wound is firmly united, catheterism may be stopped. 




Fig. 89. — Dressing for excision of the 
upper jaw 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



91 



Perineal plastic operations on the female require a previous thorough 
disinfection of the vulva and vagina by mercurial irrigation, which should 
be kept up during the entire time of the operation. Here, too, dressings 
are annoying and unnecessary. Catheterism, temporary confinement of the 
bowels, and frequent and generous dusting with iodoform powder will afford 
all the security needed against infection. 

Aside from the care for the production and maintenance of the aseptic 
condition during and after the operation, another important requirement 
must be fulfilled. This is a thorough and complete apposition of the entirety 
of the wounded surfaces by several tiers of catgut sutures, and a correct 
union of the mucous membranes of the vagina, and of the rectum if necessary. 
A slovenly manner of suturing will lead to the formation of hollow spaces, 
which will become filled by blood-clot ; and, if the sutures of the mucous 
membranes be also inexact, contact of the vaginal or rectal discharges with 
the unprotected clot will lead to its inevitable putrescence, and to partial 
or general suppuration. An exact deep and superficial suture is the best 
protection of perineal operative luounds against infection, 

Note. — The stitches holding the mucous membrane together should never pass through the 
epithelium. They should be entered and brought out just below the epithelial lining. This 
will prevent inversion of the edges, and the stitch-holes will be also protected from infection by 
the ridge of protruding mucous membrane. 

On account of the great vascularity of the face, facial wounds will often 
heal without suppuration, even if very indifferent asepticism was observed. 

Not so in other parts of the body, notably about the extremities, where 
suppuration is much more easily produced, and is generally followed by 
sloughing of the flaps. Strict asepticism, avoidance of tension by sutures 
and of pressure by dressings, are imperative conditions of success in plastic 
operations done on the extremities. 




Fig. 90.- 



-Maas's operation. Primary plaster-of-Paris dressings. On the right leg, the defect 
to be covered ; on the left leg, flap detached from calf. 



Case I. — Abraham Strecker, aged seven. Circular, extensive skin defect of the 
right leg, due to old compound fracture; extensive ulceration of frontal part of the 
cicatrix ; oedema of the foot, caused by contraction of the circular cicatrix. Dec. 7, 



92 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



1885. — At Mount Sinai Hospital, plastic repair of the frontal part of the defect by Maas's 
procedure. Each thigh and foot was first incased in a plaster-of- Paris splint, then the 
cicatrix was disinfected with an eight-per-cent solution of chloride of zinc and pared off 




Fig. 91.— Maas' 



operation. Secondary plaster-of-Paris dressings fixing relative position of 
extremities. Flap attached to its new habitat. 



with the scalpel. After this a properly shaped, generous skin-flap was raised from the 
posterior aspect of the left leg. Now the extremities were superimposed in such a manner 
as to bring the flap over the vivified surface of the right leg, wherewith it was brought 

in contact on its raw surface. A second- 
ary plaster-of-Paris dressing applied over 
the primary plaster splints secured the 
limbs and the flap in their new relative 
position. The exposed raw surface of the 
pedicle of the flap was wrapped in an 
envelope of rubber tissue to prevent its 
desiccation ; the flap was lightly attached 
to its new habitat by a few catgut sut- 
ures. The edges of the flap were dust- 
ed with iodoform, and the defect of the 
calf was inclosed in an aseptic dressing. 
With the exception of a small portion 
of the end of the flap which necrosed, 
primary union throughout was achieved. 
Dec. 21st. — The pedicle of the flap was 
cut, and the limbs were released from 
their confinement. Rapid cicatrization 
of the remnant of the original and of the 
defect of the calf followed, and, January 
30, 1886, the boy was discharged cured. 
The cedema of the foot had disappeared. 
Case II. — Adolph Carstens, school- 
boy, aged eleven. Feb. 17, 1887.— At 
the German Hospital, Maas's operation 
for a large skin defect of the anterior 
aspect of the tibia, due to severe traumatism. The case was managed exactly like the 
foregoing one, with this additional circumstance, however, that it became necessary 
to pare off an area of the anterior aspect of the tibia by chiseling, corresponding to 




Fig. 92.— Maas's op- 
eration, final result. 
Cicatrix is marked 
with ink. 



Fig. 93. — View of ci- 
catrix of the place 
whence the skin-flap 
was taken. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 93 

the size of the flap, in order to remove the condensed cicatricial tissue underlying the 
extensive elevated ulcer. Thus, a well- vascularized base was secured for the skin-flap. 
March 3d.— The pedicle was divided, and, April 10th, the patient was discharged cured. 

VII. ASEPTICS OF THE ORAL CAVITY. 

Long after the principles of the aseptic treatment of external wounds 
nad become recognized, the proper management of the wounds of the nor- 
mal openings of the respiratory, digestory, and urogenital tracts was still a 
mooted question. It was a comparatively easy thing to produce in these 
regions an aseptic condition for the time of the operation. But how to 
protect the wounds from the inevitable soiling by the continuous discharges 
pertaining to these several apertures, was first shown by Billroth, who suc- 
cessfully employed iodoform as an effective preventive of putrefaction in 
the oral cavity. 

If a fresh wound of the oral cavity is rubbed off with iodoform powder 
and packed with gauze saturated with iodoform, this dressing will become 
matted together with the tissues of the raw surface, and will form an 
effective protection against infection by septic influences. The secretions 
will innocuously pass over the surface of the gauze, and the penetration of 
active germs to the wound will be prevented by the air-tight and closely 
adherent packing. 

The course of oral wounds treated in this manner differs widely from that 
observed under other forms of treatment. Diphtheritic and phlegmonous 
processes, formerly so common in wounds freely communicating with the 
mouth, have become things of great rarity. The terrible odor which could 
not be kept down by however frequent irrigations with, any kind of deodor- 
izing lotion until the necrosed layer of tissues was cast off, is now generally 
absent. By the time that the packing of iodoformed gauze becomes loose, 
healthy and vigorous granulations will have sprung up, and the wound will 
progress toward its uninterrupted healing without pain and without fever. 

As long as the packing is firmly adherent, it should not be disturbed. 
Its forcible extraction would certainly cause a good deal of pain, and would 
be followed by haemorrhage and inflammation. The superficial layers of 
iodoformed gauze, becoming soiled by secretions or food, can be daily 
renewed. 

Another important point to be observed in operations about the oral 
cavity is the control of haemorrhage. The abundant blood-supply of this 
region is apt to be the source of copious haemorrhage, dangerous in itself, 
out especially perilous on account of the possibility of the entrance of blood 
into the air-passages. 

This accident may, on the one hand, cause instant death from suffoca- 
tion ; on the other, it may produce catarrhal or septic pneumonia by decom- 
position within the bronchi. 

Haemorrhage from oral wounds can be controlled in two ways. They 
jnay be employed separately or combined. 
14 



94 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 94. — The author's tracheal tampon cannula. 



The first one is by preliminary ligature of one or both lingual arteries ; 
the second, by the exclusive use of the actual cautery and galvano-caustic 
wire loop. 

Where the operation must needs extend to the floor of the mouth, deli- 
gation of the lingual arteries will be insufficient, and the use of the actual 
cautery point or loop often impracticable. In such a case, preliminary 
tracheotomy and the employment of a tampon cannula will be the only safe 

means of preventing 
the entrance of blood 
into the bronchi. 

Although White- 
head's speculum is an 
excellent instrument 
to render the oral cav- 
ity accessible, yet it 
will be unsatisfactory 
in operations to be 
done on the floor of 
the mouth. Here sec- 
tion or even partial 
excision of the lower 
jaw may be unavoidably necessary to afford ample space for complete excis- 
ion of a malignant tumor, and to make accurate hsemostasis practicable. 

Where most or all attachments of the tongue to the inferior maxilla must 
be severed, a strong loop of silk should be drawn through the stump of the 
tongue near the epiglottis, to be brought out by the mouth and attached 
by a strip of adhesive plaster to the cheek. This precaution will enable the 
nurse or attendant to instantly clear the epiglottis should the stump of the 
tongue ever slip back upon and occlude the entrance to the larynx. 

In the more extensive cases of oral surgery, especially after removal of 
the tongue, nutrition will have to be carried on for some time by the stom- 
ach-tube, which can be left in for several days, or can be daily introduced 
by the mouth or nostril. 

Early operations for cancer of the tongue will give better results in every 
way than late ones. But even of the latter it can be said that, as a rule, 
the patient's life will be prolonged by them, and will be made more tol- 
erable. 

Every oral operatiou should be preceded by a careful preparation of the 
mouth by extraction of carious teeth and frequent washings with a germi- 
cide lotion, preferably a 1 : 1,000 solution of permanganate of potash. Pres- 
ent stomatitis should be first got rid of by all means. 

Case I. — Mr. David S., wholesale butcher, aged fifty-four. Strong smoker. On the 
inner aspect of the right cheek, opposite a carious and sharp-edged molar, where an 
opaline mucous patch had existed for some time, an elevated ulcer of the size of a 
silver dollar had established itself, and was steadily extending. The submaxillary 
lymphatic glands were intumescent. April 30, 1884" — Extirpation of the growth from 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 95 

a transverse incision extending backward from the angle of the mouth. The outer 
skin was saved and brought together by a line of stitches. The intumescent submax- 
illary glands were also removed. Uninterrupted recovery followed, but a small fistula 
remained behind, corresponding to the middle of the incision of the cheek, which, how- 
ever, closed after a few applications of the thermo-cautery. The contraction of the 
cheek was successfully overcome by the insertion and wearing of wooden wedges, which 
were abandoned in the fall of 1884. During the summer a relapse of cancer had 
developed in the deep-seated submaxillary glands of the right side and in the submen- 
tal gland. September 25, I884. — The glandular swellings were extirpated from both 
mentioned regions. The complete removal of the submaxillary glands necessitated 
excision of two inches of the deep jugular vein. The wound healed by the first inten- 
tion; the patient took his first walk twelve days after the operation. He remained 
free from the disease until September, 1885, when a rather rapid swelling of the sub- 
maxillary glands of the left side was observed. Apparently the infection had extended 
to the opposite side of the neck by way of the diseased submental gland. The original 
site of the epithelioma in the cheek remained intact by relapse. October 22, 1885. — An 
attempt was made to remove the glandular swelling of the left side of the cheek, but 
it had to be abandoned on account of the wide extension and infiltrating character of 
the new growth. January 31, 1886.— Patient died of extension of the disease to the 
cerebrum. 

Had the first operation been undertaken at an earlier date, the respite 
secured to the patient would have been much longer. 

Case II. — Katie Johs, aged thirteen. Mucous cyst of the left under side of the 
tongue, deeply imbedded in the lingual tissues, and extending back to the hyoid bone. 
March 24, 1883. — Deligation of the left lingual artery from an external incision above 
the hyoid bone. Whitehead's speculum being inserted, the tongue was transfixed and 
secured by a strong fillet of silk. By this it was withdrawn, and the cyst was easily 
extirpated from its bed by means of scissors and forceps. Care was taken not to grasp 
the cyst with the mouse-tooth forceps, which served only to hold aside the muscular 
tissue of the tongue. Minimal haemorrhage was observed. The wound was stitched 
with fine silk throughout its entire length, a few threads of catgut being inserted into 
its upper corner for drainage. Both wounds healed by primary union, and, April 7th, 
the patient was discharged cured from the German Hospital. 

Case III. — Adolph Bottger, cooper, aged forty -two, a strenuous smoker and hard 
drinker, had contracted an epithelioma of the right anterior margin of the tongue, ex- 
tending well forward to the gums of the canine tooth, and involving the intervening 
part of the floor of the mouth. No intumescence of the lymphatic glands could be 
made out. August 28, 1883. — At the German Hospital the right lingual artery was 
deligated, and the right half of the tongue was excised by the aid of forceps and scis- 
sors. A morphine injection had been administered before the operation, and anaes- 
thesia by chloroform was not carried to insensibility. Haemorrhage was very moder- 
ate. In excising the floor of the mouth the bleeding was somewhat profuse, and a 
large number of spurting vessels had to be tied. The resulting wound was packed 
with iodoformized gauze. No fever or inflammation followed, and the power of deglu- 
tition was re-established on the third day. The patient left the bed on September 9th, 
and October 9th was discharged cured. In February, 1884, the disease returned on 
the inner aspect of the gums. March 10th. — Three inches of the alveolar process of 
the horizontal part of the lower maxilla were excised, together with the entire cicatrix. 
Cure was delayed by necrosis of the remaining portion of the body of the jaw. April 
SOth. — The sequestrum was extracted. May 20, I884. — Patient was discharged cured. 



96 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

May 17, 1886. — The patient returned with a far-gone relapse, starting from the left 
submaxillary stump. May 19th. — Exsection was performed. Violent delirium tremens 
set in immediately after the operation, followed by death in collapse. 

Case IV. — Fritz Osterwald, shoemaker, aged sixty-three; strong smoker; cancer 
of the right margin of the tongue well back near the anterior pillar of the fauces, with 
considerable involvement of the floor of the moutb. February 2, 1886. — Deligation 
of the left lingual artery, followed by excision of the corresponding half of the tongue 
and floor of the mouth in morphine-chloroform anaesthesia at the German Hospital. 
Access was gained to the oral cavity by a semicircular incision following the under 
side of the lower jaw, from which the attachments of the muscles were raised together 
with the periosteum. The mucous membrane was cut through, whereupon the tongue 
and floor of the mouth could be drawn out from under the maxilla and turned out upon 
the front of the neck. Haemorrhage was rather free in spite of the preliminary liga- 
ture of the lingual artery ; and, though the patient was not fully anaesthetized, alarm- 
ing asphyxia suddenly took place, apparently due to the occlusion of the glottis by a 
blood-clot. Efforts to dislodge this were unsuccessful, therefore hasty tracheotomy 
had to be performed, resulting in re- establishment of respiration. After this the excis- 
ion was completed without further mishap. More than half of the tongue was re- 
moved up to the epiglottis, together with the left side of the floor of the mouth and 
the anterior faucial pillar. The wound was packed with iocloformized gauze. Nutrition 
was carried on by stomach-tube. No fever followed, but, February 15th, symptoms of 
iodoform mania necessitated the removal of the original packing, which was replaced 
by corrosive-sublimate gauze. Feb. 18th. — The restless patient was taken to his home, 
whence he was transferred to Bellevue Hospital, where he died a maniac on February 
28th. 

The foregoing case illustrates the dangers from the entrance of blood 
into the larynx, and the greatest drawback of iodoform when used on elderly 
individuals — namely, its tendency to produce acute mania. From this 
instance the author learned the lesson of never risking a rather bloody opera- 
tion in the oral cavity without preliminary tracheotomy and the use of a 
tampon cannula. The anxious moments spent in opening the suffocating 
patient's trachea will never be forgotten. 

Case V. — Victor Jeggi, silk- weaver, aged fifty-three, a very moderate smoker, 
admitted August 20, 1885, to the German Hospital with lingual cancer, involving nearly 
one half and principally the right side of the tongue. No glandular swelling. Aug. 
22, 1885. — Both lingual arteries were deligated, and two thirds of the entire length 
and width of the organ were excised with very little haemorrhage in mixed (morphine- 
chloroform) anaesthesia. The wound was packed with iodoformed gauze. Deglutition 
returned on August 28th. The wound healed very rapidly, so that, September 5th r 
patient could be discharged nearly cured. He presented himself, February 21, 1886, 
with a relapse in the floor of the month, but delayed operation until March 30th, when 
the disease had assumed formidable proportions. Preliminary tracheotomy being done, 
the author's tampon canula was inserted. The middle portion of the lower jaw was 
excised, and the remnant of the tongue was removed together with the entire floor of 
the mouth by means of the thermo-caustic knife. The stumps of the severed arteries 
did not retract (atheromatosis), and were successively tied. The wound was packed 
with iodoformized gauze, and nutrition was carried on by the stomach-tube. April 
2d. — The patient vomited, and undoubtedly some of the ejecta found their way into 
the bronchi. April 3d. — Catarrhal pneumonia set in with a chill and a temperature 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 97 

of 104° Fahr. April 6th. — The critical condition changed for the better, and by April 
15 tli the patient left the bed. To avoid vomiting produced by the frequent introduc- 
tion of the stomach-tube, this was carried in through the nostril and left in situ with 
evident comfort to the patient. The wound contracted rapidly, but in the middle of 
May relapse appeared in the pharynx, which ended the patient's existence in June, 1886. 

The presence of the tampon cannula in the trachea, effectually shutting 
off the possibility of the entrance of blood into the air-passages, made this 
otherwise very bloody and formidable operation comparatively easy and safe. 

Case VI. — Mr. Joseph T., wholesale liquor-dealer, aged sixty, a smoker, had been 
suffering for twelve years from opaline patches of the tongue, two of which, situated 
on the left side of the organ, developed, toward the end of 1886, into epitheliomata. 
The otherwise well-nourished patient suffered also from chronic interstitial nephritis, 
as evidenced by the presence of albumen and hyaline and fine granular casts in the 
urine. Feb. 10, 1887. — The left lingual artery was deligated under chloroform anaes- 
thesia. The tongue was secured by a strong fillet of silk, and was withdrawn from the 
mouth. A straight Peaslee's needle was then carried into the bottom of the deligation 
wound, and was thrust through the middle of the base of the tongue just in front of 
the epiglottis into the oral cavity. One end of a platinum wire w r as passed through the 
eye of the needle, withdrawn through the wound and disengaged. The same needle 
was reintroduced by the wound into the oral cavity, emerging this time just alongside 
of the left anterior pillar of the fauces. The other end of the wire was brought out 
by the needle through the external wound. Thus, one half of the base of the tongue 
was included in a loop, and, the wire being connected with a galvanic battery, was 
singed through without loss of blood. After this the tongue was divided longitudi- 
nally by the thermo-cautery in two unequal halves, and finally was severed from its 
connections with the floor of the mouth by the same instrument. A few spurting 
arteries had to be tied off during this last step of the operation, which was completed 
within the time of forty minutes. The haemorrhage was really insignificant, to which 
circumstance is to be mainly attributed the rapid recovery of the patient. The oral 
wound was packed with iodoformized gauze, and the external incision was dressed in 
the normal manner. The temperature remained normal throughout, and feeding by 
tube was discontinued on the third day. The mouth was irrigated every hour with a 
1 : 1,000 permanganate of potash solution, until February 18th, when the packing came 
away. The wound appeared clean, and rapid contraction was manifest. Feb. 25th. — 
The external w r ound was firmly healed. March 8th. — The oral wound was closed. 

Note. — la preparing iodoformized gauze for use in wounds of the oral cavity of elderly 
subjects, care must be taken not to sprinkle too much of the chemical upon the gauze. The 
surplus of iodoform should be rinsed out of the meshes of the fabric, which should be tinged just 
a very faint yellow color. 

VIII. LARYNGEAL OPERATIONS. 

1. Tracheotomy. — The belief that tracheotomy is an easy operation is by 
no means justified by the author's experience. Occasionally, on a slender 
neck, and when there is competent assistance to be had, it is a simple 
enough procedure. But in most cases, especially on children, it calls for 
the best qualities of an experienced and cool surgeon. 

The necessity of tracheotomy having become manifest, three require- 
ments are to be fulfilled. First, infection of the wound has to be avoided ; 



98 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



secondly, unnecessary haemorrhage has to be guarded against ; and, thirdly, 
the trachea has to be properly incised, and the cannula properly introduced 
and secured. 

The risks of the operation are not inconsiderable, hence intubation of 
the larynx, a much simpler, easier, and more physiological procedure, must 

be declared to be far preferable to tracheotomy 
where its application is proper, as in croupous 
laryngitis. 

For the removal of foreign bodies and in cases 
of tumor of the larynx, tracheotomy will remain 
the proper measure. 

Avoidance of infection of 
the wound from within or 
without is an ever important 
matter in all laryngeal op- 
erations. But it is especial- 
ly important, and also more 
difficult, in cases where the 
operation is done in the pres- 
ence of an infectious process, 
as, for instance, diphtheritic 
croup, where the extension 
of the septic condition to 
the external wound signal- 
otherwise precarious state of the 




Fig. 95. — Arrangement of the patient for tracheotomy 



Then it is dusted with iodo- 
gauze. In all cases of croup 



izes a very grave complication of the 
patient. 

The aseptic rules laid down in preceding parts of this work obtain to 
their full extent in laryngeal operations. Infection from within must be 
guarded against by careful cleansing of the external wound and rubbing 
iodoform powder into all its recesses before incising the trachea. As soon 
as the cannula is inserted, the external wound must be well mopped out with 
a sponge soaked in corrosive-sublimate lotion, 
form, and lightly packed with iodoformized 
the external wound should not 
be sutured, as sutures favor re- 
tention. A small slit compress 
of iodoformized gauze is slipped 
in under the flange of the can- 
nula before its fastening by the 
two lateral pieces of tape. By 
slipping in over the gauze com- 
press a slit piece of rubber tis- 
sue or oiled silk, the dressings and the patient's shirt will be protected from 
soiling by the sputa. A narrow roller bandage passed several times over and 
under the outer opening of the cannula will give additional security against 
accidents. 




Same in situ. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 99 

Note. — Unruly children will sometimes attempt the forcible removal of the cannula. In 
1880 the author performed tracheotomy on a boy twelve years old, who, on regaining conscious- 
ness, at once tore out the cannula from the wound, breaking its fastenings to the flange, which 
remained attached to his neck. The family attendant, an elderly gentleman, attempted the 
re-introduction of the instrument. Finally, during the violent struggles of the patient the 
cannula slipped into place, whereupon respiration, which had been labored before, suddenly 
ceased altogether. The author reached the bedside by this time, and at once removed the 
cannula from the asphyxiated child's neck, restoring respiration. It was found that the cannula 
had been introduced upward into the oral cavity, instead of downward into the trachea. Another 
tracheal tube was properly introduced, and peace was once more restored, but the boy died sub- 
sequently of septicaemia, due to the wide extent of the diphtheritic affection of the pharynx. 

Hc&morrhage, always characteristic of an overhasty and bungling opera- 
tion, can be guarded against by observing the rules laid down in the chapter 
on the technique of surgical dissection. Kothing will retard the perform- 
ance of tracheotomy as effectively as the disregard for hemorrhage. And 
every drop of blood spilt unnecessarily will proportionately diminish the 
chances of recovery, not to mention the danger of suffocation from the 
entrance of blood into the lungs. 

Note. — The author once assisted a colleague who in his anxiety to open the trachea cut 
the isthmus of the thyroid gland. The formidable haemorrhage following this step only increased 
the doctor's haste. He plunged the knife into the pool of blood and fortunately opened the 
trachea. The patient aspirated a large quantity of blood, and would have surely been suffocated 
but by the timely turning of his body face downward. The patient, a boy of seven years, recovered. 

As soon as the skin, platysma, and superficial fascia have been amply 
divided, the two groups of longitudinal muscles situated in front of the 
larynx are exposed. Sharp retractors are inserted and the bleeding vessels 
are attended to. A faint white mark indicating the median line where 
the muscles meet, is incised, and the muscles are taken up and raised by the 
retractors as the wound deepens. 

Thus far everything is easy. The most difficult part of the operation 
consists in the proper treatment of the isthmus of the thyroid gland. 

The surgeon must decide whether to approach the trachea from above or 
below the isthmus, and this decision depends upon the length of the neck 
and the size of the isthmus. In long, slender necks, the trachea is easily 
exposed below the isthmus ; in short, fat necks, with a massive isthmus, the 
upper operation is more appropriate. 

a. Superior Tracheotomy. — Having chosen the upper operation, the 
surgeon must find his way to the upper part of the trachea, situated just 
behind the isthmus, without injuring the thyroid capsule and its compli- 
cated plexus of large and turgid veins. To accomplish this, Bose's method 
affords an easy way. 

The deep cervical fascia divides into two layers just above the superior margin of 
the thyroid gland, these two layers forming the main body of the thyroid capsule. 
The point of division corresponds exactly with the upper margin of the cricoid carti- 
lage, which can be easily identified by touch. The nail of the left index finger is 
placed against the margin of the cricoid, the pulp of the finger looking downward, 
whereby the thyroid gland is protected, and the fascia is opened by a short transverse 



100 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 97. — Diagram showing relations 
of deep cervical fascia, a, Thy- 
roid body. Just above it, corre- 
sponding to cricoid cartilage, bi- 
furcation of deep cervical fascia. 



incision directed against the upper edge of the cartilage. As soon as this is done, a 
blunt hook can be introduced through the transverse slit behind the thyroid gland, 
which then can be drawn down with some force, exposing the two or three upper rings 

of the trachea. The author never saw this method 
fail, and, in employing it, never was compelled to 
cut the cricoid cartilage for want of space to limit 
the incision to the trachea. (See Fig. 97.) 

b. Inferior Tracheotomy. — When the 
lower operation is decided on, the two layers 
of the deep cervical fascia are successively 
incised between two forceps, and thus the 
trachea will be readily exposed. 

Incision of the trachea should be done 
by the scalpel used for the first part of the 
operation, and rather by cutting than by 
puncture, as the latter may injure the poste- 
rior wall of the cylinder. Before cutting it, 
the trachea should be allowed first to adjust 
itself in its normal position, so that the in- 
cision should be placed exactly in the me- 
dian line. 
Grasping of the trachea while the incision is being made, but especially 
haste in opening the organ, may lead to very serious mistakes. It may 
happen that the trachea is not incised at all, or, what is still worse, the 
incision is placed laterally or even posteriorly on the tilted wind-pipe. 

Case I. — Mary R., aged five. May If,, 1882. — Tracheotomy performed by a col- 
league for laryngeal croup. The cannula could not be kept back in the wound, and the 
patient was found by the author suffocating, the instrument lying on the outside of the 
neck. Examination showed that the tracheal incision was placed to the left side and 
posteriorly, the trachea being twisted and bent while the cannula was in situ. An 
anterior tracheal incision was made, and in this the tube was retained without trouble. 
The child died of pneumonia. 

Case II. — Hermann Mollenhauer, aged two and a half. Croupous laryngitis. 
March 27, 1881. — With the assistance of the family attendant, Dr. Hase, superior 
tracheotomy, on account of imminent suffocation. The trachea was exposed without 
trouble, but in catting it open too hastily it tilted around its axis, and the point of the 
knife shaved off a segment of the first tracheal ring. The tilting of the trachea was 
not noticed at first on account of the necessary haste ; but, as soon as it was discovered, 
the trachea was properly incised, and the child ultimately recovered. 

As soon as the proper number of rings are divided, the lips of the in- 
cision should be taken up by two small, sharp retractors. (See Fig. 18, 
page 39.) Hasty crowding in of the cannula is reprehensible, and may 
cause serious or fatal mischief by detaching and pushing membrane down 
into the deeper parts of the tracheal tube. Drawing asunder the tracheal 
wound will afford ample opportunity for free breathing, for ejection of blood 
and membrane or mucus, and will give the surgeon a welcome chance to 
inspect the trachea and to extract semi-detached membrane or a foreign 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 101 

I)ody. It will also solve the question whether tracheotomy has accomplished 
its end or not by the relief from dyspnoea. 

The apnoea, or seeming cessation of breathing, often observed imme- 
diately after the incision of the trachea, is apt to alarm beginners. It is 
due to the habituation of the patient to exist on a very small allowance of 
oxygen. The first deep and. free breath taken through a newly-made 
tracheal incision gives the patient more oxygen than ten or fifteen labored 
inspirations could give before the operation. 

As soon as the cannula and dressings are in place, the patient is brought 
to bed, and. a sponge, hollowed out in cup shape by the curved scissors, is 
attached with a safety-pin or two to a suitable piece of bandage, is wrung 
out of hot carbolic lotion (two per cent), and is tied down loosely just over 
the orifice of the cannula. It should be cleansed at frequent intervals 
in the same lotion. Close attention to the cleanliness of the interior of 
the cannula is a constant duty devolving upon the nurse. It should be 
done by chicken or pigeon wing-feathers dipped in carbolic lotion. The 
little patients should be encouraged to drink as much as possible, prefer- 
ably milk. 

The first dressings can remain undisturbed for three days ; on the fourth 
day they and the cannula are changed. The patient is laid out flat on a 
table as for tracheotomy, and everything possibly needed should be at hand 
and. readily arranged in a pan. Two sharp retractors, thumb-forceps, scis- 
sors, a clean cannula, and a change of dressings will be needed. The bandages 
are cut, and they and the cannula are simultaneously removed with the outer 
compress of gauze. The deeper packing should remain unchanged till it 
becomes detached. The fresh cannula is slipped in at once, and usually with- 
out much difficulty if the procedure be not unduly delayed. 

The packing of iodoformed gauze will become loose on about the fourth 
day, and should then be removed. If the wound is found clean and granu- 
lating, no repacking will be required. 

As soon as the patient can breathe freely through the fenestrum of the 
outer tube, the external opening of the cannula being occluded, the instru- 
ment should be removed, as it is apt to cause pressure-sores and trouble- 
some granulations within the trachea. 

The author's experience embraces thirty-eight tracheotomies performed 
for various reasons. Twenty-two were done for croupous laryngitis on chil- 
dren. Of these, five recovered ; seventeen died. The superior operation 
was employed seventeen times ; the inferior, five times. 

One of the children died of suffocation caused by the ill-advised action 
of the father, who inflated the patient's bronchi through the cannula with 
a large quantity of burnt alum. The others died of extension of the pro- 
cess to the lungs, or of septicaemia. 

Of the remaining sixteen tracheotomies done on non-croupous cases, two 
concerned children, fourteen referred to adults. 

The following table will elucidate the causes for which the operation was 
performed : 
15 



102 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Recovered. Died. 

Asphyxia from entrance of blood into trachea 1 1 

" " malignant goitre 2 

" arterial haemorrhage into a cervical abscess 1 

" " chloroform 1 

Dyspnoea from cicatricial stenosis of bronchus 1 

" " " " pharynx 1 

" " foreign body in trachea 1 

" " larynx 2 

" " laryngeal tumor 8 1 

Preliminary tracheotomy 1 

Total „ . , . 9 1 

Of the two cases operated on for the entrance of blood into the larynx, 
one recovered (see Case IV on page 96) ; the other, where hemorrhage came 
from a suicidal gunshot wound of the base of the skull, died of the cerebral 
injury. 

In two cases the operation was done for threatening asphyxia by growing 
malignant goitre. Both died : one from collapse ; the other from coma, 
produced by acute alcoholism or traumatic delirium (see Cases I and II on 
page 109). 

In one case asphyxia caused by haemorrhage into a cervical abscess neces- 
sitated the operation. Patient recovered (see Case III on page 217). 

In two cases tracheotomy was done for deep-seated stenosis of the air- 
ducts without success. 

One concerned a man of forty, in whose left bronchus post-mortem examination 
revealed a syphilitic cicatricial stenosis. The other bronchus was found compressed 
by acute swelling of a bronchial lymphatic gland. 

The other case was that of Fred. Peckary, aged one, who exhibited symptoms of a 
growing tracheal stenosis, principally obstructing expiration. The case came, March 
6, 1886, under the author's care by the kindness of Dr. Boldt. Tracheotomy was done 
at the German Hospital without relief. . The child died of pneumonia March 10th. On 
autopsy a brass trousers-button was found imbedded in old cicatricial tissue between 
trachea and oesophagus, midway between the cricoid cartilage and the bifurcation. An 
open communication existed between the two tubes. The button was held in place by a 
rim of cicatricial tissue in the oesophagus, and projected downward with its free lower 
margin like a valve into the lumen of the trachea. Thus inspiration found no impedi- 
ment, but on expiration the valve was raised, and expiration-stenosis was the result. 

In one case syphilitic stricture of the fauces indicated the operation. 
Patient survived. 

In four cases the trachea was opened on account of the presence of laryn- 
geal tumors. Three survived, and one died of septic pneumonia, due to 
aspiration of the intensely fetid secretion of the ulcerated tumor. 

Preliminary tracheotomy was done once successfully before extirpation 
of the cancerous tongue (see Case V on page 9G). 

In one case the trachea was opened on account of acute asphyxia occur- 
ring during chloroform anaesthesia. 

Case. — Undersized boy, aged nineteen. November 12, 1885. — At Mount Sinai Hos- 
pital removal of an enormous congenital teratoma of the occipital region under chloro- 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 103 

form. The growth had become sarcomatous, and extensive involvement of the cervical 
glands of both sides was present. The patient had to be placed in the prone position, 
and this and his generally weak state, together with the encroachment on the trachea by 
the glandular swellings, produced asphyxia toward the end of the operation. As arti- 
ficial respiration did not seem to produce any effect, tracheotomy was performed at 
once, and respiration was restored. While the pedicle of the tumor was being de- 
tached, it was noted that respiration had again ceased. The cannula was found outside 
of the tracheal wound, from which it was allowed to slip by the assistant intrusted 
with the narcosis. It is fair to state that death was very likely due to exhaustion or 
collapse induced by the shock of the formidable operation upon the much emaciated 
patient. He was a lad of nineteen, but looked like a very sickly child of ten. 

In one case increasing stenosis, caused by the presence of a dispropor- 
tionately small tumor, indicated the operation. 

Case. — Julius Meyer, peddler, aged thirty-nine. Previous history pointed at the 
lodgment of a foreign body in the oesophagus with dysphagia, which spontaneously 
disappeared. Gradually, however, increasing dyspnoea supervened. The laryngoscope 
demonstrated the presence of a small irregular tumor in the larynx, the size of which 
did not seem to explain the intense dyspnoea. Tracheotomy was done December 18, 
1886, at Mount Sinai Hospital. On incising the trachea above the thyroid body, a 
granuloma occupying the posterior and lateral aspect of the larynx just below the vocal 
chords was exposed. Surrounded by this mass was found the point of a wooden skewer, 
one inch in length, its ends being imbedded in the mucous membrane. The cricoid 
cartilage was divided, the body was extracted, and the granuloma was excised. Dec. 
27th. — Tracheal tube was removed. (For continuation, see Case III on page 104.) 

The following history of the removal of a foreign body from the larynx 
of a child concludes the series of the author's non-croupous cases of trache- 
otomy ; 

Case. — Clara V., aged five and a half. May 22, 1887. — A foreign body entered 
the larynx of the patient, causing intense fits of coughing and transient attacks of chok- 
ing. A number of unsuccessful attempts at endolaryngeal removal of the body were 
made the same day. Finally, the body became lodged in the right 
bronchus, where its -presence was made out by the sibilant noise 
heard near the bifurcation and the absence of normal respiration 
sounds over the entire right lung. A short, hacking cough, moder- 
ate dyspnoea, and noisy respiration served as constant reminders of 
the impending danger. June ll^th. — During a coughing spell, sud- 
denly an alarming asphyctic attack set in, followed by dysphagia, Ftg. 98.— Min- 
aphony, hoarse, croupy cough, and distressing dyspnoea. Marked mture doll, re- 
larnygeal stridor and diminished respiration sounds over both lungs larynx by tra- 
pointed to the lodgment of the foreign body in the glottis. Inferior cheotomy. 
tracheotomy being performed, the dyspnoea at once disappeared. The (Clara V.) 
foreign body, a headless and armless miniature doll of porcelain, five 
eighths of an inch long and three eighths of an inch wide, was found firmly wedged 
in the glottis, whence it was extracted through the wound without difficulty. The 
wound was treated openly, and the child recovered. (See Fig. 98.) 

2. Laryngofissure. — Fission of the larynx for the removal of tumors or 
a foreign body was performed three times by the author. In one case of 
recurrent diffuse papilloma a very good final result was secured. In another 




104 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

one, done for epithelioma, speedy relapse followed. In the third case the 
presence of a foreign body and inflammatory granuloma required the step. 
The body and new-growth were removed, but the perichondritic inflamma- 
tion maintained for a very long time such an intense swelling of the laryngeal 
mucous membrane that the tracheal cannula had to be worn until June, 1887. 

Case I. — Mrs. C. Lehmann, twenty-four, epithelioma of both vocal cords. April 11, 
1881}. — At the German Hospital, laryngofissure and extirpation of both vocal cords and 
the adjacent mucous membrane were done. April 15th. — Cannula removed. April 30th. 
— Wound healed. Relapse manifesting itself soon afterward, excision of the larynx was 
done in the summer of the same year by Dr. F. Lange, who took charge of the service 
at the German Hospital after the expiration of the author's term. 

Case II. — David Popplewell, machinist, aged forty-two ; recurrent papilloma of 
the larynx, that had been treated endolaryngeally by Dr. Gleitsmann, who kindly 
directed the patient to the author. July 9, 1885.— Laryngofission at the German 
Hospital. Removal of the posterior half of right vocal cord ; excision of several 
disseminated papillomata and searing of their base by the thermo-cautery. August 
5th. — External wound healed; voice much improved. 

Case III. — Julius Meyer, peddler, aged thirty-nine ; recurrent stenosis after trache- 
otomy (see case on page 103) done, December 18, 1886, for the removal of a foreign body 
and granuloma from the larynx. January 21 ', 1887. —Laryngofissure. Moderate return 
of the new-growth about the defect of the mucous membrane in which the end of the 
wooden splinter had been found imbedded. The probe was introduced into this aper- 
ture, and penetrated downward and backward to a distance of three fourths of an inch, 
thin pus exuding from the sinus. Intense swelling and hyperemia of the entire mucous 
membrane and submucous tissue were noted. Perichondritis was diagnosticated, and a 
tracheal tube was left inserted in the wound. The patient readily recovered from the 
operation, but subsequently could not get along without a cannula till June, 1887. 

To prevent the entrance of blood into the bronchi the author tried the 
use of a tampon cannula in each one of the preceding cases. It had to be 
abandoned, however, as, taking up too much space, it cramped the operator. 
It was found quite satisfactory to press into the lower angle of the laryn- 
geal wound a small sponge, leaving enough space below it for the admission 
of air. 

3. Extirpation of the Larynx. — There is no doubt in the author's mind 
that partial or total extirpation of the larynx for malignant new-growths, if 
done early, is the correct treatment, and will be successful in direct proportion 
to the readiness and thoroughness with which it is done. This view is in full 
accord with the accepted principles of the treatment of malignant neoplasms 
of all other regions of the body. The large rate of mortality recorded so 
far after extirpation of this organ is due in a great measure to the fact, that 
the step was resorted to mostly in otherwise hopeless and desperate cases, 
in which endolaryngeal therapy had utterly failed to give relief. 

The earlier the operation is done after due establishment of the diagnosis, 
the less radical it need be. Unilateral extirpation of the larynx is far less 
dangerous than the total removal of the organ, and, as a number of success- 
ful cases testify, even a fair degree of phonation, together with unimpaired 
deglutition, may be preserved by it. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 105 

Case T.* — Paul Halm, barber, aged fifty. November, 1879. — Increasing dysphagia. 
Dr. E. Gruening diagnosticated an elevated ulcer of the size of a half-dollar coin, occupy- 
ing the depression bounded by the right side of the base of the epiglottis, the right side 
of the base of the tongue, and the right wall of the pharynx, a site corresponding to 
that of the glosso-epiglottic and aryteno-epiglottic folds, and more particularly to that of 
the sinus pyriformis. The mucous covering of the epiglottis was seen to be thickened 
and congested. The cervical glands did not appear to be affected. No evidence of 
syphilis could be elicited, either from the history or from the physical examination of the 
patient, excepting a moderate degree of onychia, characterized by roughening of the 
finger-nails. In the course of the treatment it became evident, however, that this latter 
trouble was due only to the fact that, in pursuing his trade, his fingers were much ex- 
posed to the action of soap-lather. 

A nti- syphilitic treatment was instituted and continued for some time with apparent 
benefit, the patient regaining to a certain extent the ability to swallow. The improve- 
ment was, however, merely temporary ; the dysphagia returned, and the patient soon 
began to suffer from the inanition thus engendered. 

Preliminary tracheotomy was performed January 18, 1880, at the German Hospital. 
March 5, 1880. — Unilateral exsection of the larynx was done with the able assistance of 
Drs. Gruening, Bopp, Lefferts, and Dr. Degner, the house-surgeon, to whom great 
credit is due for the skill and patience exhibited in the difficult and tedious after-man- 
agement of the case. 

An incision was carried from the median line of the hyoid bone along its upper 
margin outward to the extent of three inches, exposing the right lingual artery, which 
was ligated. A second incision was carried downward from the starting-point of the 
first, in the median line, to the opening for the cannula, exposing the anterior surface of 
the hyoid bone and larynx, and the flap thus formed was dissected up with all the 
underlying soft parts and turned outward. Trendelenburg's tampon-cannula had been 
fitted into the trachea. The right half of the hyoid bone was then exsected, a double 
ligature placed around the superior laryngeal artery, and the same divided. The crico- 
thyroid ligament was cut across, a pair of bone scissors inserted into the larynx, and 
the thyroid cartilage divided in the median line. Trendelenburg's tampon cannula did 
not fulfill the requirements owing to a leak in the inflated bladder, so that blood man- 
aged to find its way into the trachea. An attempt to make it serviceable by winding 
layers of moistened gauze around the cannula was unsuccessful, and during the rest of 
the operation it became necessary to fill out the lower part of the larynx with small 
sponges. The interior of the larynx was now exposed and showed an oval tumor, of 
about the size of a pigeon's egg, situated in the substance of the right false vocal cord, 
involving the posterior half of the true vocal cord and the small cartilages belonging 
to it. The right half of the thyroid and the whole of the arytenoid cartilage were 
now dissected up and removed, together with the whole epiglottis. The pharynx being 
thus exposed to view, its entire right side was seen to be diseased, and was removed, 
together with the right tonsil and the lower half of the right pillars of the palate. The 
base of the tongue, likewise involved, was dissected up on the right side with the 
scalpel, on the left with the thermo-cautery. The haemorrhage was insignificant, and 
the patient rallied promptly after the operation. 

One of Tiemann's excellent soft-rubber tubes was introduced into the oesophagus, 
the wound thoroughly cleansed with a ten-per-cent solution of zinc chloride, and the 
whole cavity packed with moistened balls of carbolized cloth. The edges of the hori- 
zontal incision were then united by catgut sutures. 

* " Archives of Laryngology," vol. i, No. 2, June, 1880. 



106 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The oesophageal tube was remarkably well tolerated, and the patient's nourishment 
was satisfactorily effected through it during the whole course of the treatment. 

The dressing was changed once every twenty-four hours. 

On the fifth day after the operation the patient was well enough to sit up in a 
chair for an hour. Three days later he could ascend a flight of stairs in being removed 
to another room, and a week later he spent most of his time out of bed. By the 1st 
of April, twenty-six days after the operation, he took a walk in the garden, and his 
weight had increased by 6^ pounds. 

The large cavity contracted rapidly, and finally became a canal, bounded on one 
side by the remaining half of the larynx, on the other by a smooth cicatrix uniting the 
skin with the mucous membrane of the posterior wall of the pharynx. 

On the 29th of April the patient made a first attempt to speak. When the tracheal 
tube was closed, he could converse with a hoarse, dull voice, quite audible, and easily 
understood at a distance of from two to three yards. His ability to swallow has in a 
measure been recovered, but he preferred to use the oesophageal tube, to which he had 
become accustomed. By the 5th of May he had gained 14| pounds in weight. 

The patient continued well until February, 1881, when he contracted an acute 
pleurisy, to which he succumbed rather suddenly on account of fatty heart. The speci- 
men of the larynx gained at the post-mortem examination showed absence of any sign 
of a relapse. 

The tumor was found to be an adeno- sarcoma. 

Case II.* — Henry O., porter, aged fifty-seven. Rebellious hoarseness of five 
months' standing, with increasing difficulty of deglutition. Marked loss of flesh and 
power. March 16, 1885. — When the patient was directed to the author by Dr. S. W. 
Gleitsmann, a deep-seated, nearly immovable, hard, glandular swelling of the size of a 
hen's egg was noted in the left submaxillary triangle. Endolaryngeal inspection 
revealed the presence of a smooth, pale tumor, the size of an almond, commencing in the 
left glosso-epiglottidian fold and extending through the substance of the left vocal 
cord into the ary-epiglottidian fold, to terminate in the arytenoid cartilage with a knob- 
like protuberance. March 18th. — Chloroform being administered, the diseased glands 
were removed. The sterno-mastoid was found partly involved, and this, together 
with a piece of the internal jugular vein of about one and a half inch in length, was 
removed in one mass. Then inferior tracheotomy was performed. The wound healed 
kindly, except where the tracheal tube was located, and April 27th, under chloroform, 
the left half of the larynx was removed. A tampon cannula, made by George Tiemann 
& Co. after the author's directions, was inserted and suitably distended so as to pre- 
vent the entrance of blood into the trachea. After this an incision, commencing at 
the upper notch of the thyroid cartilage and extending to the lower margin of the 
cricoid cartilage, laid bare the larynx in the median line. To this was added another 
incision, commencing in the upper angle of the first cut and extending horizontally to 
the anterior margin of the left sterno-mastoid muscle. The crico thyroid ligament was 
split to admit a strong pair of bone-pliers for the division of the thyroid cartilage ; but 
it was found impossible to perform this act, as the strongly inclined position of the 
cartilage did not permit an effective handling of the instrument. Therefore, access 
was gained through an incision in the thyro-hyoid ligament from above, and in this 
manner an exact division of the calcified cartilage was successfully effected. After 
this the epiglottis was cut through lengthwise, the left half of the crico-thyroid liga- 
ment was divided, and the superior thyroid artery was included in a double ligature 
and cut through. The most difficult part of the operation consisted of the dissection 
of the lateral portions of the larynx and pharynx, closely adherent to the carotid artery 

* " Annals of Surgery," January, 1886, p. 20. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 107 

by cicatricial tissue, caused by the extirpation of the submaxillary glands. Shallow 
incisions, running parallel with the course of the carotid artery, were cautiously made 
one after another, and the difficult task seemed almost completed when suddenly a 
powerful jet of arterial blood welled up from the bottom of the wound. The bleeding 
point was easily secured in a pair of artery forceps, and then it was ascertained that 
the trunk of the superior thyroid artery (doubly ligated further below prior to this) 
had been cut away on a level with its inosculation into the carotid. A catgut liga- 
ture was applied around the main trunk above, another below the artery forceps, and 
when the instrument was removed a round hole in the side of the carotid became visi- 
ble. The remaining adhesions, corresponding to the lateral portion of the pharynx on 
the left side, could now be easily dissected out. The tampon cannula was removed, and 
it was found that no blood whatever had entered the trachea. A soft tube was in- 
serted into the oesophagus, the wound was loosely packed with iodoformed gauze, and 
an ordinary tracheal cannula was left in the lower angle of the tracheal wound. Finally, 
the horizontal incision was closed by a number of catgut sutures. The duration of the 
operation was one hour and three quarters — the anaesthesia throughout undisturbed. 

Microscopical examination of the new-growth by Dr. L. Waldstein gave the diag- 
nosis of alveolar sarcoma. 

The subsequent course of the wound was very satisfactory and free from fever or 
suppuration, the patient's only complaint being a rather profuse secretion of saliva. 
Nutrition was carried on by the oesophageal tube, the patient consuming considerable 
quantities of milk, eggs, and an emulsion composed of beef-tea and crushed boiled beef; 
finally, a generous supply of good whisky. 

From May 10th on, the oesophageal sound was introduced twice daily for purposes 
of nutrition. On May 13th the tracheal cannula was abandoned. On the same day 
the innermost layers of the iodoformed gauze packing became detached, and were 
replaced. The entire wound was found to be in a vigorous process of granulation, and 
was considerably contracted. 

May 15th. — The patient swallowed a small quantity of coffee. 

May 27th. — Sutures were removed ; wound firmly united. Increase of body weight 
four and a half pounds. May 81st. — Patient was discharged cured from the hospital, 
good deglutition being noted. June 12th. — Removal of a small, suspicious gland from 
the left supraclavicular space. March 13, 1886. — Removal of an enlarged lymphatic 
gland from left suprahyoid region. Since then the patient remained well, attending 
to his laborious occupation. He could speak with a very audible hoarse intonation. 
The right vocal cord performed its function normally. In March, 1887, relapse 
appeared in the cicatrix about the insertion of the stump of the epiglottis, for which 
subhyoid pharyngotomy was performed, April 22, 1887, at the German Hospital. A 
portion of the cicatrix, together with a section of the base of the tongue, was removed. 
The external wound was united by three rows of superimposed catgut sutures. Deg- 
lutition was hardly disturbed by the operation; the external wound healed by adhe- 
sion, and, May 3d, patient was discharged cured. 

In both of the preceding cases decided alleviation of the patients' 
wretched condition and an undoubted prolongation of life were achieved. 

IX. GOITRE. 

The aseptic method and an improved technique of dissection have 
materially reduced the formidable perils of the surgical treatment of goitre, 
justly dreaded by old-time practitioners. 



108 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

In goitre encroaching upon the trachea, the question must be first de- 
cided whether the growth is cystic or parenchymatous. If cystic, various 
forms of treatment offer a fair chance of cure. The cyst can be tapped and 
injected with tincture of iodine, like a hydrocele ; or it can be exposed by 
dissection, incised, and its walls sutured to the skin, like the sac in hydro- 
cele operated on by Volkmann's method. 

Case. — Lena Kaiser, aged thirty-five. Cystic goitre of the thyroid body. It was 
as large as a child's fist, and the source of much discomfort to the patient on account 
of the severe dyspnoea it produced. November 23, 1882. — At the German Hospital, 
exposure of the capsule of the goitre. A plexus of much-distended veins was included 
in two sets of double mass ligatures, between which the capsule was cut into. The 
parenchyma of the gland was divided, and the sac of the cyst being exposed was 
incised and attached to the skin by two continuous sutures. The cavity was packed 
with carbolized gauze. December 22d. — Patient was discharged cured. 

Where the presence of a number of contiguous cysts is made out, their 
enucleation will be appropriate. The procedure is not difficult, and offers 
the additional advantage of the possibility of primary union and a speedy 
cure. 

Case. — Hannah S., servant, aged thirty-one. January 16, 1886. — At Mount Sinai 
Hospital, extirpation of four contiguous cysts of the thyroid body. Flap incision; the 
thyroid capsule was cut into between two rows of mass ligatures; after this the cysts 
were shelled out without difficulty. The wound was drained and sutured. Primary 
union. Patient was discharged cured February 21st. 

Parenchymatous goitre may be treated with some hope of success by the 
methodical injection of tincture of iodine in cases in which the tumor is 
soft and vascular. Should this plan fail, or when the tumor is very dense 
and hard, excision must be performed. 

Total removal of the thyroid gland is apt to produce a deep alteration of 
the general condition denoted " myxmdema" or "cachexia strumipriva," 
characterized by idiotism, loss of sexual power, and general dense cedematous 
infiltration of the subcutaneous connective tissue ending in death. Hence, 
a portion of the glandular tissue ought to be always left behind to perform 
its function, so necessary to the healthy state of the nervous system. 

The principles laid down for the safe removal of tumors (page 50) should 
guide the surgeon in exsecting thyroid swellings. Haemorrhage from the 
large veins of the capsule is to be avoided by the timely use of Thiersch's 
spindles and of double ligatures. Dissection should be systematic and de- 
liberate, and especial care should be devoted to the preservation of the re- 
current laryngeal nerve, which will be found behind the lateral lobe of the 
thyroid gland in the groove separating the trachea from the oesophagus. 

Case. — Kosa Eosenfeld, cook, aged twenty-four. Parenchymatous hyperplastic 
goitre of the body and right thyroid lobe, causing severe dyspnoea. October 9, 1884- — 
At Mount Sinai Hospital, extirpation of the right lobe and body of the gland from a 
spacious flap incision. A pedicle was formed toward the left lobe, and, being first liga- 
tured, was cut off. In dissecting up the right lobe, which was found to be insinuated 
between the trachea and oesophagus, the recurrent laryngeal nerve was separated and 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 109 

drawn aside. Drainage, suture, and aseptic dressings. The wound healed, with the 
exception of the drainage-tracks under the first dressing, which was changed on Octo- 
ber 19th Some hoarseness due to paresis of the right vocal cord persisted for five 
months, but ultimately disappeared. 

Tracheotomy for goitre is one of the most formidable tasks the surgeon 
may be called upon to perform. It was twice the author's duty to under- 
take this procedure for extreme dyspnoea caused by malignant tumor of the 
thyroid gland. One case was complicated by mitral insufficiency and acute 
bronchopneumonia, and ended fatally. In the other one the supra-sternal 
portion of a very large fibro-sarcoma of the thyroid gland had to be first 
extirpated before access could be had to the trachea. This case also ended 
lethally. 

Case I. — Rosa Guttmann, widow, aged thirty-six. Large and growing originally 
parenchymatous, later sarcomatous, substernal goitre of five years' standing. Mitral in- 
sufficiency and severe acute broncho-pneumonia. Dr. S. Kohn, who referred the patient 
to the author, diagnosticated paralysis of the right vocal cord. November 11, 1879. — 
Patient was admitted to German Hospital in a very exhausted condition. After copious 
stimulation tracheotomy was performed. Only a very small amount of ether was admin- 
istered for the cutaneous incision. Division of the goitre by the thermo-cautery was 
tried, but had to be given up on account of the slowness of the process and the great 
haemorrhage from the enormously distended veins. The expedient of at once taking 
up and firmly retracting the divided tissues by large, four-pronged, sharp hooks, proved 
more efficacious in checking haemorrhage. With a few rapid strokes the trachea was 
exposed and opened, and, a large-sized soft catheter being introduced, respiration be- 
came well established. But a few minutes afterward patient expired. 

Case II. — Elizabeth K., aged sixty-two. A very fat woman, with a small pulse, 
suffering from extreme dyspnoea due to the presence of a very large and hard supra- 
and infra-sternal fibro-sarcomatous goitre. August 23, 1882. — Extirpation of the 
supra-sternal part of the swelling w 7 ith subsequent tracheotomy, for which a specially 
constructed cannula with a long tube was used. Relief of dyspnoea. Copious stimula- 
tion was employed by the family attendant to such an extent that in the night of 
August 24th the patient became boisterously drunk, and died in a soporous condition 
under the symptoms of acute alcoholism. 

X. AMPUTATION OF THE BREAST. 

In preantiseptic practice the rate of mortality observed after amputa- 
tion of the breast, mainly due to accidental wound complications, was nearly 
as high as that of major amputation of the limbs. 

The notable depression of the death-rate that has taken place since is 
directly due to cleanlier methods. 

The absence of a proportionate decrease of the death-rate, caused by re- 
lapse of the malignant growths for which the operation is performed, is to 
be attributed to the tardiness of the general practitioner in advising and 
urging early removal, and the unwillingness of the patients to heed timely 
advice. 

In view of the fact that over ninety per cent of all mammary tumors 
are carcinomatous, the benefit of the doubt belongs to the view which urges 
16 



110 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



to removal. A probatory incision at least should be insisted on in every 
case of solid chronic intumescence of the breast that remains uninfluenced 
by proper local and general treatment directed against syphilis or chronic 
inflammatory mastitis. 

Partial operations are admissible only where the youth of the patients, 
the smoothness and mobility and slow progress of the tumor justify the 
assumption of a benign growth, such as adenoma or adeno-fibroma, or 
where probatory puncture leaves no doubt of the presence of a simple re- 
tention cyst. 

In these cases the operation proposed by T. G. Thomas is very appro- 
priate, and gives satisfactory results both as to the completeness of the re- 
moval and the cosmetic effect. The incision is laid in the pectoro-mammal 
fold, and the breast-gland is raised from the pectoral fascia sufficiently to 
enable the surgeon to incise it on its posterior aspect. After the enucleation 
of the tumor the breast is replaced, and, the wound being drained, the 
skin is united by an exact suture. The cicatrix remains hidden under 
the overlapping breast. 

Case I. — Miss C. L., governess, aged twenty. Adenoma of left breast of the size 
of a hen's egg. December 12, I884. — At Mount Sinai Hospital, Thomas's operation. 

December 22d — First 
change of dressings. 
December 2Ifth. — Dis- 
charged cured. De- 
cember 12, 1886.— 7$ o 
relapse ; very fine lin- 
ear cicatrix. 

Case II. — Miss 
Tillie G., aged six- 
teen. Adeno-fibroma 
of left breast of the 
size of a small apple. 




Fig. 99. — The mammary gland being detached from below, the surgeon inserts his left hand 
under the breast to complete the upper section. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. HI 



December 20, 1886. — Thomas's operation at Mount Sinai Hospital. December 30th. — 
Dressings changed. January 4, 1887. — Wound firmly united. 

Whenever amputation of the breast is performed for malignant tumor, 
the operation must be radical, or at least as radical as possible. No regard 
whatever should be paid to cosmetic considerations, the object of the measure 
being the extirpation of a deadly disease, which, if not eliminated, is sure 
to kill. A wide berth should be given to the visible limits of the disease, 
and the knife should take away at least an inch and a half of apparently 
healthy skin. The axillary fat and glands must be invariably removed in 
mass, whether intumescence is to be felt or not. 

If the axillary vein be attached to degenerated lymphatic glands, the 
attached segment must be included in two ligatures, and the intervening 
piece cut out, together with the adherent mass. 

The technique of breast amputation is simple. After marking by a 
shallow cut the extent of the two semi-elliptic incisions that should include 

the part to be removed, the infe- 
rior margin of the breast-gland is 
exposed. The pectoral fascia be- 
ing incised, the mamma is gradu- 
ally dissected up from the thorax 
till its upper limit is reached. 
The surgeon's hand is slipped in 
under the breast, and the upper 
incision completes its detachment, 
except where the lym- 
phatic vessels, pass- 
ing along the pecto- 
ral fold from the 
breast to the arm- 
pit, form a sort of a 
pedicle. The bleed- 
ing vessels are secured 
as they are cut, and 
the pectoral wound is 
covered with a towel 
wrung out of corros- 
ive-sublimate lotion, 
to remain under its protection during the removal of the axillary contents. 
The incision is extended well up the arm into the axilla, and the skin is dis- 
sected up for about an inch to each side of the cut. The fascia is divided 
where the incision can be made boldly upon the edge of the pectoral muscle 
anteriorly, and the latissimus dorsi posteriorly. Proceeding from this latter 
incision, the loose connective tissue is divided by blunt dissection with a 
thumb-forceps and the handle of the scalpel, until the axillary vein is 
exposed to view. With this the most important step of the operation is 
accomplished. Seeing the vein will prevent its accidental injury, and from 




Fig. 100.— Eemoval of axillary contents. The surgeon holding 
the detached breast serving as a handle. 



112 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



this on, in most cases, dissection will be directed away from instead of toward 
the vein. The loose fat can be easily detached from all its lateral adhesions. 




Fig. 101. — Sutured wound after amputation of breast. Counter-incision through latissimus for 

purposes of drainage. 

The vessels and nerves which traverse the adipose tissues can be distinctly 
felt and seen as they are successively approached. If necessary the long 
thoracic artery and vein, and sometimes the subscapular vessels, should be 




Fig. 102. — Completed dressing after breast amputation. 

taken up and cut between two forceps. During the dissection of the axillary 
contents, the breast serves as a suitable handle. Breast and axillary con- 
tents are removed in one mass. Thus the intervening lymphatic ducts are 
certainly taken away together with the mammary gland and the axillary 



SPECIAL APPLICATION OF, THE ASEPTIC METHOD. 113 

lymphatic glands. After due irrigation, a counter-incision is made on the 
external aspect of the latissimus-dorsi muscle. The knife should divide 
the skin and fascia only ; then a dressing-forceps is thrust through the 
muscle into the most dependent part of the axillary wound, when it is made 
to grasp the end of a stout drainage-tube, which is drawn out through the 
counter-incision, to be transfixed with a safety-pin and clipped off even 
with the skin. 

After this the pectoral wound is united. Lister's plate suture, or a 
quilled suture, or any other of the known forms of retentive suture, is 
applied to relieve tension. After another irrigation, the fine catgut sutures 
of coaptation are put in until the wound is closed. The wound is once 
more flushed out with mercuric lotion, and is covered with the dressings, 
care being taken to make them the thickest about where the drainage-tube 
issues forth. The dressings are secured by roller-bandages, and the arm is 
either included in the turns of the bandage, the ulna first being well padded, 
or, being left out, is supported by an extra sling. 

Ordinarily, the dressings are changed and the tube is removed on the 
tenth day after the operation, when the retention sutures are also extracted 
should they not have been absorbed by this time. A smaller dressing secures 
the parts against injury. Five days later another change of dressings may 
take place, when the drainage opening will be found closed by a plug of 
granulations. After this a covering of cerate or lead plaster, with a little 
pad of cotton secured by a strip of adhesive plaster, will be all that is neces- 
sary until cicatrization is complete. 

It is remarkable how soon the arm regains its power of abduction in cases 
that remain free from suppuration. 

Of fifty operations for tumors of the mammary gland, forty-eight were 
done on women mostly past middle life ; two were performed on men. The 
male cases were as follows : 

Case I. — A. B., aged seventeen. Growing adenoma of right mammary gland. 
August 4, 1883. — Extirpation of the tumor ; axilla was not interfered with. Uninter- 
rupted primary union. 

Case II. — George Eckert, blacksmith, aged sixty. Large, very hard epithelioma 
of the right mammary gland, starting from the nipple, which was unrecognizable in 
the ulcerated mass. Axillary glands involved. April 27, 1886. — Amputation of breast 
and evacuation of axilla at the German Hospital. Large portions of skin and of the 
pectoralis major and minor muscles had to be removed. Primary union followed, 
except where the skin could not be brought together. June 7th. — Discharged cured. 

In two cases of adenoma of young girls, the tumor alone was removed. 

In five instances (Mary Hauser, adeno-cystoma ; Emma Bockhold, cysto- 
sarcoma ; Albert Baron, adenoma; Sarah S., cysto-adeno-fibroma ; Frida 
Meissner, adeno-fibroma), the mammary gland alone was amputated, the 
axillary space remaining intact. 

The remaining forty-three cases consisted of thirty-eight cancers and five 
sarcomata. In each of these the entire breast and all the axillary contents 
were removed. 



114 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Cancer 38 

Sarcoma 6 " 

Adenoma 3 " 

Adeno-fibroma ... 2 " 

Adeno-cystoma 1 case 

Total 50 cases 

Of this number, forty-one times healing by primary union was observed. 
Five cases suppurated in consequence of infection of one or another kind 
at the time of the operation ; three cases healed by granulation, as it was 
impossible to cover the defect caused by the operation. A fourth granulat- 
ing case died of erysipelas, contracted outside of the author's care (Julie 
Schmalz, scirrhus) while the wound was not yet healed. 

Of the cases healed by primary adhesion, one died of continuous throm- 
bosis of the axillary and anonyma vein, with subsequent embolism of the 
pulmonary artery. The sudden change took place shortly after the first 
change of dressings, made eight days after the operation. 

Case. — Clara Halm, spinster, aged thirty-two. November 30, 1883. — Amputation 
of left breast, with evacuation of axilla for small-celled adeno-carcinoina; suture; no 
drainage. December llf.th. — First change of dressings; entire wound absolutely healed. 
On Christmas eve the patient was selling crockery over the counter. April 4, 1885. — 
Typical amputation of right breast at the German Hospital for the same affection, 
together with excision of relapsing cancer in the shape of a small node in the .cicatrix 
of the left side. Patient was doing excellently till April 12th, when the first dressings 
were changed, and the wound was found faultlessly healed. Immediately after the 
dressings were completed, the patient became faint and cyanosed; breathing labored, 
pulse scarcely to be felt; the left deep jugular vein was permanently distended. 
Hydropericardium and hydrothorax developed with oedema of both arms, and the 
patient died April 20th, sixteen days after the operation, having had normal and later 
subnormal temperatures throughout. Autopsy revealed continuous thrombosis of left 
axillary and anonyma vein, the thrombus extending into the right auricle and the 
pulmonary artery ; bilateral hydrothorax, hydropericardium, and a hemorrhagic in- 
farction of the connective tissue in the posterior mediastinum. 

The only unusual circumstance that attracted the author's attention 
immediately before the second and fatal operation was the fact that, a hypo- 
dermic injection of morphia being administered, extensive ecchymosis ap- 
peared shortly afterward at the site of the injection, suggesting a morbid 
alteration of the patient's vascular system. 

Thrombosis and embolism were observed in another case, which, how- 
ever, ended in cure. 

Case. — Mary Lier, school-teacher, aged fifty-seven. Suffering from old pulmonary 
emphysema and chronic bronchitis. Face slightly cyanosed. Scirrhus of right breast ; 
nipple retracted, discharging dark, tar-like serum. November 14, 1878.— With the kind 
assistance of Dr. F. Lange, amputation of right breast and evacuation of the axilla were 
performed. Anaesthesia by ether was very bad. Feverless course of healing. Novem- 
ber 19th. — Drainage-tube was removed. November 23d. — Apoplectiform seizure, fol- 
lowed by aphasia and agraphy, which, however, gradually disappeared. December 
29th. — The wound was entirely healed, and patient could again speak Bohemian, her 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 115 

mother tongue. Gradually she regained her German and English, and in 1882 author 
heard from her as being able to write again. 

One of the suppurating cases died of acute catarrhal pneumonia and 
carcinosis of the lungs, twenty- two days after the operation, the wound 
doing well at the time under process of granulation. 

Case. — Mary Volkmer, housewife, aged forty-seven. Soft adeno-cancer of both 
breasts, the large tumor of the left mamma causing much distress. March 17, 1881. — 
At the German Hospital amputation of left breast and evacuation of the axilla were 
done. Wound was united in part only on account of extensive loss of integument. 
Suppuration of axillary space followed, but the fever resulting therefrom subsided 
directly after drainage was re-established. Nevertheless, patient appeared to be very 
ill. April 8th. — Catarrhal pneumonia set in, to which she succumbed. April 9th. — 
On post-mortem examination general carcinosis of lungs and liver and catarrhal 
pneumonia were found. 

In computing the three fatal cases, that of Julie Schmalz, who died of 
erysipelas contracted under the care of another physician before perfect 
cicatrization had taken place, can justly be excluded. Accordingly, of the 
remaining forty-nine cases, two died directly in consequence of the opera- 
tion, none, however, on account of septic processes established in the wound. 
Thus, the author's rate of mortality from accidental wound infection in 
amputation of the breast would be ; from other causes beyond the in- 
fluence of the surgeon, a trifle more than four per cent (4*08). 

XI. ABDOMINAL OPERATIONS. 

1. General Remarks. 

The relation of aseptics to the surgical treatment of the peritoneal cavity 
is in some quarters a subject of hot controversy to this day. On one side 
we see the advocates of a more or less complicated antiseptic apparatus, 
including the spray, achieving very good results, and basing success upon 
the strict enforcement of their cautelae. But, on the other hand; we notice 
a most successful laparotomist maintaining that antiseptics are unnecessary, 
or even harmful, and that he is accustomed to flush the peritoneal cavity 
with " water from the tap," teeming with millions of bacteria, and yet his 
results vie with those of the most scrupulous Listerian. 

Both sides to the controversy have abundant and incontrovertible facts 
to support their positions, and the contradiction seems to be hopelessly in- 
surmountable. It certainly is extremely bewildering to the student and 
beginner. 

Yet this contradiction is unreal, and let us say, on one side, also disin- 
genuous. 

The physiological peculiarities of the peritonaeum, most notably its enor- 
mous absorbent power, endow it with the quality of neutralizing the deleteri- 
ous effects of limited quantities of pyogenic or septic micro-organisms, a 
quality not possessed to such an extent by any other part of the human 
organism. 



116 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Grawitz * has brought experimental proof of the fact that the normal 
peritonaeum will at once absorb into the circulation moderate quantities of 
active pyogenic cocci, where they will be widely scattered through the blood 
and perish. 

Note. — This fact goes very far to explain Lawson Tait's position, who, however, although 
disclaiming antiseptics, devotes most scrupulous care to asepticism — that is, to the cleansing of 
hands and instruments. His instruments are few, and selected with a view to simplicity. His 
sponges are put into carbolic lotion for disinfection. The water used for the immersion of his 
instruments is sterilized by boiling. Most of the bacteria contained in his " water from the 
tap " are innocuous — that is, non-pyogenic ; and those that have the power to cause suppuration 
are too few to produce serious trouble. They are simply absorbed and killed off by the great 
germicide, the blood. 

The limit of the quantity of pyogenic cocci required to produce acute 
purulent peritonitis varies with the size and state of health of the animal 
used in the experiment. A large dog's peritonaeum would resist a much 
greater quantity of infectious pus than that of a small dog or rabbit. And 
a healthy animal would neutralize more septic material than a debilitated 
one of the same kind and weight. 

The presence in the peritoneal cavity of a larger quantity of stagnant 
bloody serum than can be readily absorbed within an hour, will suffice to 
produce purulent peritonitis on the addition of a very small number of 
cocci. 

If the fluid is absorbed or artificially removed by drainage before the 
cocci have a chance to vastly multiply, no peritonitis or only adhesive forms 
of the inflammation will develop. 

Therefore, it is rational to employ drainage in cases where large surfaces, 
denuded of peritonaeum, have to be left behind in the abdomen. 

Denudation of the surface layer of the peritoneal endothelium by caloric, 
or mechanical or chemical influences, is also conducive to the development of 
purulent peritonitis. It favors exudation of serum, and diminishes or de- 
stroys the power of absorption inherent to the normal peritonaeum. Should 
even a minute quantity of pyogenic cocci be introduced into the peritoneal 
cavity under these circumstances, purulent peritonitis may readily develop. 

The practical conclusions to be drawn from the preceding facts are as 
follows : 

1. Although the normal peritonaeum will tolerate a greater quantity of 
infectious material than most surgical wounds, yet all precautions regarding 
the cleansing of hands, instruments, sponges, and other apparatus used for 
laparotomy should be employed, as septic infection of the peritonaeum is 
much easier to prevent than to cure. 

2. Unnecessary denudation of the uppermost layer of the peritonaeum 
should be avoided as much as possible. 

3. Corrosive solutions, as, for instance, of carbolic acid or mercuric bi- 
chloride, are not to be used on the peritonaeum. As soon as the peritoneal 
cavity is opened, Thiersch's solution should be employed for rinsing the 

* " Charite Annalen," xi. Jahrg., page 770. 



SPECIAL APPLICATION OF t THE ASEPTIC METHOD. 117 

surgeon's hands, immersing the instruments, sponges, towels, and, if 
necessary, for irrigation. 

4. A careful toilet, that is, removal of all exuded serum or blood, should 
precede closure of the abdominal wound. 

5. Where large denuded surfaces have to be left behind, and a good deal 
of oozing is to be expected, drainage must be employed. 

Note. — If the drain-tube is brought out from a dependent part of the peritoneal cavity, 
as, for instance, through Douglas's cul-de-sac, the secretions will escape spontaneously by the 
operation of the law of gravity. Whenever the drainage-tube is brought out above the symphysis, 
the scrum collecting at the bottom of the cavity mus* be removed either by hourly mopping out 
with a stick, armed with a pad of absorbent borated cotton, or by exhausting with a long-nozzled 
syringe, introduced to the bottom through the hollow of the drain-tube. 

6. Should it become evident that the mode of drainage employed is in- 
sufficient to remove a copious gathering of secretions, febrile symptoms, 
tenderness, and tympanites developing on the first few days after the opera- 
tion, a saline purge may be employed in preference to the accustomed 
opium treatment (Tait). Its object would be to favor rapid absorption of 
the effused serum in an analogous manner seen with the administration of 
cathartics for the rapid removal of hydropic accumulations from the abdomi- 
nal cavity. 

7. If purulent peritonitis be undoubtedly established, reopening and 
irrigation of the peritoneal cavity with a hot 1 : 5,000 solution of corrosive 
sublimate may be taken into consideration, provided that the patient's gen- 
eral condition should warrant such a procedure. 

2. Herniotomy. 

In the main, the success of herniotomy depends upon the condition 
of the strangulated gut at the time of the operation. With aseptic pre- 
cautions, as long as the gut is not necrosed, herniotomy is fraught with 
very little danger. From the moment that intestinal gangrene has set in, 
the preservation of asepticism becomes extremely difficult. Contact alone 
with the decayed gut is infectious. Laceration of the friable intestinal wall 
is very likely to occur on employment of the least amount of force, and 
usually leads to further contamination by escaping intestinal contents. 

In addition to this, the general condition of patients with intestinal 
necrosis is mostly wretched. Systemic intoxication, and the tendency to 
heart-failure induced by constant vomiting, vastly increase the perils of 
anaesthesia and haemorrhage, and the prognosis is thereby rendered all the 
more doubtful. 

The free exhibition of anodynes, especially in the shape of hypodermic 
injections in the presence of strangulated hernia, is very often followed by 
fatal consequences. The most acute symptoms are blurred or blotted out 
entirely, and a false sense of security is apt to lull the apprehensions, and 
to betray patient and physician into undue procrastination. 

Out of the thirty-one cases of herniotomy performed by the author both 
for strangulation and for the radical cure of the complaint, eight died. 
17 



118 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Six aut of this number exhibited necrosis of the gut, and all of these died. 
Of the remaining two, one, whose gut was sound, died of acute nephritis, 
presumably due to the use of ether as an anaesthetic ; the other one of 
general tuberculosis of the peritonaeum. 

Case I. — A. Schlesinger, aged seventy-three, strangulated left inguinal hernia of 
twenty-four hours' standing. April 12, 1885. — At Mount Sinai Hospital, the hernial sac 
was exposed under ether anaesthesia. A knuckle of gut could be felt within the sac, con- 
taining a cubic, friable body that was easily crushed, whereupon the gut was replaced 
in the abdominal cavity without any difficulty. The wound was sutured and dressed. 
Duration of the operation, twenty minutes. The wound healed by primary adhesion, 
but uraemic symptoms, with suppression of the renal secretion and vomiting, developed 
on the second day. The scanty urine was found contaiuing blood and a large amount 
of albumen. April 22d. — The patient died in uraemic coma. 

Inquiry elicited the fact that, preceding the day of the patient's illness, 
he had largely consumed of a dish of potato soup. The toothless old man 
had bolted some of the potato, a piece of which having made its way into 
the hernia caused strangulation. 

The other fatal case, not due to necrosis of the gut, was as follows : 

Case II. — Mrs. Henrietta Bolz, housewife, aged sixty, an ill-nourished, emaciated 
person, who said that she had been suffering from belly-ache and constipation for two 
months, and that she has had severe, and continuous fever that caused her present 
emaciation. She also noted that she had lost most of her hair. Forty-eight hours pre- 
vious to her admission, irreducible femoral hernia of the right side was diagnosticated 
by a medical man. Vomiting, no fever, and great tenderness over the abdomen were 
found, and it was deemed proper to explore the hernia. Accordingly the operation 
was done, May 7, 1887, at the German Hospital. After incision of the sac, this was 
found to contain a portion of adherent omentum, together with a very much congested 
knuckle of small gut. The strangulating band was incised, the gut withdrawn, and, 
being in a viable condition, was replaced. The protruding portion of omentum was 
liberated, tied, and cut off. In replacing it, extensive adhesions of the stump to the 
parietal peritonaeum could be felt inside of the abdominal cavity. The sac was excised 
and the wound closed and dressed in the usual manner. May 12th. — Change of dressings. 
The wound was found united, but the general condition of the patient had remained 
the same as before the operation. Gradually considerable ascites developed, the 
patient continuing to complain of much colicky pain ; the vomiting and lack of appetite, 
together with rebellious constipation, seemed to justify the assumption of a general 
morbid condition of the peritonaeum, namely, either tuberculosis or a neoplasm. May 
26th. — The peritoneal cavity was reopened at the site of the cicatrix left by herniotomy, 
and extensive tubercular degeneration of the entire peritonaeum, with dense infiltration 
of the omentum and almost universal agglutination of the intestines, were found. The 
parietal peritonaeum and the gut were literally covered with a mass of miliary white 
nodules. With a view to relieving the obstruction caused by the multiple adherence 
of the bowels, a protruding part of the thick gut was attached to the wound by a 
number of catgut stitches, and the external incision was packed with iodoformized 
gauze. May 28th. — The bowel was found well united with the parietal peritonaeum, and 
an artificial anus was established by incising the gut and sewing the mucous mem- 
brane to the skin. Sufficient stools followed, but the patient died, March 31st, of 
exhaustion. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



119 



The case is interesting on account of the coincidence of tuberculosis 
of the peritonaeum with strangulation of a femoral hernia of old standing. 
Of course, successful herniotomy could not avert impending death. 

Twenty- three (including those subjected to the radical operation) of the 
author's total of thirty-one herniotomized patients recovered. 

a. Herniotomy for Strangulation. — If gentle and not too prolonged 
efforts at reduction, first without then with anaesthesia, do not succeed, 
herniotomy should be done forthwith. 
The mode of procedure is as follows : 

The patient's inguinal region is shaved and scrubbed off 
with soap and hot water, and is disinfected with mercuric 
lotion. Towels wrung out of corrosive-sublimate solution are 
arranged about the field of operation, and a free incision is 
made over the hernial swelling down upon the sac. The in- 
cision should extend 
well above the ingui- 
nal or femoral ring, 
and should freely ex- 
pose the place where 
the hernia emerges 
from the abdominal 
wall. By doing this 
the surgeon will be 
enabled to divide the 
constricting band un- 
der the guidance of 
the eye, and without 
the necessity of in- 
serting the probe-pointed knife into the inguinal or femoral canal, a cir- 
cumstance that may, even in the hands of a cautious and expert surgeon, 
lead to cutting or laceration of the intestine, especially if it be very brittle, 
or necrosed, or adherent. 

Case III. — Philip Trumann, aged two years and three months, was presented to 
the author December 11, 1881, with a soft, fluctuating, scrotal swelling of the left side, 
which, however, could not be by pressure reduced in size. Congenital hydrocele was 
diagnosticated nevertheless, as the tumor showed transparency. Puncture with a 
hypodermic needle brought out intestinal contents. There were no signs of strangula- 
tion, therefore cold applications were ordered, and the child's mother was told to return 
the next day. By December 12th all symptoms of strangulation, with rather high 
fever and inflammation of the swelling, had developed. Herniotomy was done at the 
German Dispensary. In opening the sac, the gut was inadvertently incised. It was 
found that local peritonitis of the sac, with extensive fresh adhesions, presumably due 
to escape of fecal matter through the puncture-hole, had taken place. The gut was 
detached everywhere by the finger-tips, the parts were well disinfected by free irriga- 
tion with a two-per-cent solution of carbolic acid, and the slit in the intestine was 
closed with a Lembert suture of catgut. The strangulating band was then cut, and, 
the intestine being replaced, the wound was sewed up, drained, and dressed. Un- 




Fig. 



103. — Patient ready for herniotomy (or for any other 
operation about the genital region). 



120 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 104. — Herniotomy. Cutaneous incision. 



interrupted recovery followed. January 12, 1882.— -The patient was discharged 
cured. 

The sac is carefully opened between two forceps, and, if possible, at a 
place where there is no adhesion to the gut. After free division between 

two thumb - forceps, 
a careful inspection 
of its contents, gut 
or omentum, or both, 
should be made. This 
will be very much 
facilitated by taking 
up the edges of the 
incision made into 
the sac with a num- 
ber of artery forceps, 
which will serve as 
handles to unfold it 
to a funnel, which 
can be easily looked 
over. (Fig. 105.) 
Generally the gut will appear deeply congested, purplish, or brownish 
red. As long as it is turgid, and is seen to contract on pinching, it may 
be assumed to be viable. 

But it still remains to be ascertained whether the points of strangulation 
be alive or not. To 
do this the strangu- 
lating band or bands 
must be first cut to a 
sufficient extent. 

Attempts to with- 
draw the gut before 
the strangulation is 
completely removed 
may lead to very seri- 
ous consequences, es- 
pecially where necro- 
sis of the strangulated 
portion of the intes- 
tine is present. 

Case IV. — J. Schrank, 
saloon-keeper, aged fifty- 
nine. Left inguinal stran- 
gulated hernia of five days' standing. Herniotomy, March 8, 1886, at the German Hos- 
pital. The sac contained a large mass of adhering omentum, and a knuckle of deeply 
congested small intestine. It was thought that the strangulating band, corresponding 
to the internal abdominal ring, had been sufficiently incised, and a very gentle and 




Fig. 



105.— Herniotomy. The opened hernial sac is held apart 
for inspection by a number of artery forceps. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 121 

unsuccessful attempt was made to withdraw the gut. The tip of the index was rein- 
serted as a guide, and, the constriction being completely divided, the gut was easily 
withdrawn. At the same moment a considerable quantity of fecal matter was seen to 
escape. It was found that necrosis of the neck of the strangulated knuckle of gut had 
taken place, and that it had been torn or cut during the preceding efforts at liberation. 
The intestine was still further extracted, and was attached to the skin by a few silk 
sutures. After careful disinfection, the neck of the sac was loosely packed with strips 
of iodoformized gauze, and the wound was inclosed in a moist dressing. The collapsed 
patient died two hours after the operation. 

In cases like the preceding one, the classical practice of invaginating the 
tip of the index into the inguinal canal or femoral ring, for the purpose 
of cutting the strangulating band, is dangerous, as it may lead to injury of 
the brittle gut. 

The author has found the gradual division of all tissues from without 
inward much safer, although it must be admitted that the division of the 
fibrous tissues located above the place of strangulation is extensive, and often 
practically converts herniotomy into laparotomy. 

With a few exceptions, the author has always employed open division 
of the strangulating bands of tissue, and never had reason to regret it. In 
some of the complicated cases he was thereby enabled to at once gain a very 
clear insight into the relations of the hernia, and in a great measure the 
ultimate success of the operation was attributed to that advantage. 

Case Y. — Fred. Bormann, laborer, aged thirty-three, had been treated at the Ger- 
man Hospital without success during several days for internal intestinal obstruction 
marked by the usual symptoms. On closer inspection, slight oedema of and somewhat 
indistinct resistance at the right inguinal region was noted. January 17, I884. — An 
incision was made exposing the external inguinal ring, which was seen to be normal. 
The incision was further extended, and, when most of the fibrous layers surrounding 
the inguinal canal had been divided, a small but well-defined tumor could be seen and 
felt occupying the inner aspect of the abdominal wall near the internal orifice of the 
inguinal canal. The abdominal wall was completely divided, and then a small hernia, 
located between the parietal peritonaeum and the abdominal wall, was exposed. The 
sac being incised, a knuckle of small gut wa^ found contained within it. The place of 
strangulation was at the neck of the sac. This was completely slit open, the gut was 
reduced, and, the neck of the sac being closed by a purse-string ligature, it was cut 
away entirely. The incision in the abdominal wall was closed by three tiers of catgut 
sutures. Primary union followed. February 16th. — Patient was discharged cured. 

Case YI. — Mr. M. S., aged thirty- six. Left inguinal hernia, that had been repeat- 
edly incarcerated, but was reduced each time. April 8, 1885, it came down again, 
and, after prolonged and very energetic efforts, the physician in charge succeeded in 
replacing it, but the symptoms of strangulation, notably vomiting and absence of alvine 
evacuations, persisted. April 12th. — Herniotomy at Mount Sinai Hospital. No ex- 
ternal tumor could be seen, but on palpation a dense resistant swelling could be felt 
in the inguinal region within the abdominal wall. The region of the external abdom- 
inal ring was freely exposed by an ample incision, and the abdominal wall was divided 
above Poupart's ligament. The hernia which had been reduced in mass was then 
reached, and was pushed out through the inguinal canal. The remaining portion of 
the intervening abdominal wall was divided, together with the place of strangulation, 



122 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

and, the sac being tied and cut away, the abdominal wound was closed with three 
tiers of strong catgut sutures. The wound healed kindly. May 15th. — Patient was- 
discharged cured. 

It may be said, then, that open division offers great advantages, espe- 
cially with regard to the avoidance of injury to necrosed or very brittle gut, 
and that its only drawback — the increased size of the incision — is vastly 
overbalanced by the security gained therefrom. If the gut be found ne- 
crosed, it can be safely withdrawn from the ample aperture, and establish- 
ment of an artificial anus can take place after securely packing the neck of 
the protruding knuckle of intestine with a sort of embankment of iodo- 
formized gauze. This packing of gauze serves as a diaphragm against infec- 
tion of the peritoneal cavity. 

Out of nineteen cases of herniotomy done for strangulation, undoubted 
gangrene of the gut was present at the time of operation in four. In 
two of these the necrosed part of the gut was injured within the inguinal 
canal by the unavoidable manipulations in liberating the intestine. In 
those cases where external or open section was used, the integrity of the 
much-decayed gut was preserved. In these latter cases the gangrene ex- 
tended to the free part of the gut, and was taken notice of before dissolving 
the strangulation. In the former cases, however, in which the gut was 
inadvertently injured, gangrene was limited to the exact locality of the con- 
striction, and was diagnosticated only after the mishap. 

The practical lesson to be drawn from this experience is that open incis- 
ion of the inguinal canal should be done whenever very acute strangulation 
has existed for more than four or six hours. 

All the patients upon whom necrosed gut was found died either of col- 
lapse, shortly after the completion of the operation, or of peritonitis due 
to infection extending from the place of strangulation. 

On one of them resection of the necrosed part of the gut was practiced, 
with subsequent suture. The patient died of peritonitis. 

Case VII. — Catharine Ihle, housewife, aged sixty-one, a very fat woman, having 
a large incarcerated umbilical hernia, was operated September 24, 1881, at her rooms 
in the presence of the family attendant, Dr. Arcularius. Open section of constricting 
bands, circumscribed necrosis of the neck of the protruding mass of transverse colon. 
Exsection of six inches of thick gut and of a triangular piece of meso-colon, and sub- 
sequent enterorrhaphy with fine catgut ; closure of abdominal cavity. Peritonitis 
developed during the following night, and, September 25th, patient died with enormous 
tympanites. 

Immediate exsection of the necrosed gut has little to commend it. The 
dangers of infection of the peritonaeum are almost insurmountable, the com- 
prehensive preparations required for enterorrhaphy are usually not made, 
and, the work being extemporized, generally lacks exactitude. In addition 
to this, the general condition of the patients is commonly so bad, that undue 
prolongation of anaesthesia itself would be very dangerous. Therefore, in 
these cases, the establishment of an artificial anus is the only proper thing 
to do. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 123 

To young physicians the decision of the question, whether the gut 
be alive or necrosed, may offer a good deal of difficulty. The responsi- 
bility is great, and uncertainty about a point of such importance extremely 
perplexing. Where necrosis is fairly established, the shriveled, parchmeut- 
like appearance, the yellowish-gray color, the absence of reflex motion on 
pinching, and the great fragility will at once characterize the condition. 
But where necrosis is just developing — that is, where thrombosis of the 
terminal vessels with bloody infarction has gone so far as to surely com- 
promise the integrity of the gut, but the signs of necrosis are as yet unrec- 
ognizable — decision may be very difficult indeed. 

The causes producing intestinal necrosis are not identical in different 
cases. Local, well-circumscribed necrosis, limited to the extent of the 
strangulating ring, and very often found in femoral hernia, is due to local 
anaemia produced by the pressure of the constricting band. 

In other cases the local pressure exerted by the constricting band upon 
the neck of the hernial contents may be insufficient to destroy the vitality 
of the intestine in actual contact with the constricting tissues. But press- 
ure that would be hardly sufficient to cut off arterial supply, will often com- 
press to such an extent the veins leading aioay from the strangulated gut 
as to completely arrest circulation. Venous engorgement and gangrene 
of the convex portion of the intestinal knuckle are then inevitable. 

The decision whether a portion of intestine, subjected to prolonged acute 
anaemia by local pressure, is viable or not, is comparatively easy. In many 
of these cases, absent circulation is often restored to the bloodless parts under 
the eyes of the surgeon. As soon as the constriction is relieved, minute red 
streaks are seen to spring up across the formerly pale, bloodless area ; they 
increase in number, and finally the parts in question assume a rosy hue and 
a normal appearance. 

Sometimes, however, recovery of circulation is tardy. In these cases, 
after amply dividing the strangulating band, a catgut thread should be 
passed through tire mesentery of the questionable loop of intestine, which 
then should be temporarily replaced in the abdominal cavity. The time 
required for restoring the circulation of the gut is usefully employed in 
attending to such other procedures as may be indicated under the circum- 
stances. Dissection and removal of adherent omentum, or the dissection 
of the hernial sac, will thus occupy some time, by the end of which the loop 
of intestine can be withdrawn from the belly for examination. If the con- 
ditions be found satisfactory, the thread should be removed, and the opera- 
tion finished in the usual way. 

Case VIII. — Theresa Wagenglast, cigarmaker, aged thirty -nine, contracted, April 
11, 1887, strangulation of a femoral hernia of old standing, situated on the left 
side. April 15th. — Admitted to German Hospital with incessant vomiting, induced 
mainly by the administration of calomel. Immediate herniotomy. » A considerable 
portion of adherent omentum presented, and was tied off in several portions and 
removed. After this a very small knuckle of gut became visible, which showed an 
anaemic area corresponding to the locality of constriction. Recovery being tardy, a 



12T RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

thread of catgut was passed through the mesentery, and the knuckle was replaced in 
the abdomen through the well-divided femoral ring. In the mean time the sac was 
excised. After the completion of this step, requiring about fifteen minutes, the gut 
was re-extracted for examination, and circulation was found fully re-established. The 
gut being replaced, the neck of the sac was closed with a purse-string suture, and was 
pushed well up in the femoral ring. Drainage and suture of the external wound. 
April 15th.— The drainage-tube was removed. April 29th. — Patient was discharged 
cured. 

Where impending gangrene from venous engorgement is to be feared, 
the decision is generally more difficult than in the preceding class of cases. 
Where immediate solving of the momentous question is impossible, the 
benefit of the doubt should always belong to the assumption that necrosis 
is to be expected. In these cases the neck of the hernial sac should be well 
divided to secure the best circulation possible, and the loop of gut should 
be so attached to the skin by a couple of sutures passed through the mesen- 
tery as to leave the questionable spots exposed to view. Thorough disin- 
fection by wiping with sponges wrung out of Thiersch's solution, a light 
packing of iodoformized gauze around the neck of the knuckle, and a moist 
aseptic dressing (the gut being covered by a protective strip of rubber tissue) 
should be applied. If the gut decay, this will take place outside of the 
peritoneal cavity. Should it recover, the fact will be manifest within one 
or two hours after the operation. The gut should be then well disinfected, 
liberated by gentle manipulation from its newly-assumed position, and 
replaced in the abdominal cavity. 

Case IX illustrates the consequences of the replacement of the gut of 
doubtful vitality. It was the author's first herniotomy. 

Case IX. — John Philip lores, waiter, aged fifty -three. Very acute strangulation 
of twelve hours' standing of an old, right inguinal hernia. October 27, 1878. — Herni- 
otomy in presence of Dr. L. Bopp, the family physician. Two knuckles of deeply- 
injected small intestine, aggregating to the length of ten inches, and a mass of dark- 
blue omentum were found in the sac. But, as the gut seemed to be turgid and viable, 
it was replaced. The omentum was pulled out, tied and cut off, and the stump was 
replaced. Septic symptoms set in immediately after the operation, with high fever 
and very great debility. October 29th. — Unmistakable signs of peritonitis, notably 
enormous meteorism, appeared. The restless patient disarranged the dressings during 
his tossing in bed, and, while vomiting, the adhesions of the wound gave way, and 
a large loop of intestine prolapsed. Necrosis of a portion of the prolapsed gut was 
evident. As much of it as was normal was replaced, the decayed part of the 
gut was incised, and fixed near the external wound. The patient died shortly 
afterward. 

It must be added that, according to then prevailing notions (1878), the 
sac and its contents were washed with a strong solution of carbolic acid 
(5 : 100) before the gut was replaced. Superficial erosion of the intestinal 
peritonaeum may have had its share in precipitating both gangrene and peri- 
tonitis. 

Necrosis of the vermiform appendix was observed by the author once 
with fatal termination. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 125 

Case X. — Henrietta Bauland, aged forty-seven. Right femoral hernia of forty- 
eight hours' standing. April 18, I884. — Herniotomy at the German Hospital. Vermi- 
form appendix was found attached by its apex to the side of the sac ; a knuckle of 
small intestine was embraced in the loop formed by the vermiform appendix, and then 
doubly incarcerated. Manipulation was very difficult, on account of the narrow space 
and the complicated state of things. The gut was slightly torn, but no intestinal con- 
tents escaped. Two Lembert's sutures being applied, the strangulation at the neck of 
the sac was relieved and the gut was liberated. The middle part of the vermiform 
appendix was found necrosed, and, a ligature being applied above this part, the appen- 
dix was cut away. The gut was returned. The patient got on very well until April 
2oth, when perforative peritonitis developed. April 21th. — Patient died. No post- 
mortem could be secured. 

However desirable thoroughness and deliberation may be in herniotomy, 
undue prolongation of anaesthesia is an evil fraught with especial danger in 
cases of long-continued strangulation, on account of the cardiac debility 
present. When the patient's vitality has been much lowered by continuous 
vomiting, loss of sleep, and septic fever, even a brief anaesthesia may be 
sufficient to precipitate fatal collapse. Habitual users of alcohol and obese 
individuals are very poor subjects to endure anaesthesia in the presence of 
necrosis of the gut. 

Case XI. — Albert P., drayman, aged thirty-five, moderate but steady consumer of 
beer and whisky. Incarcerated right inguinal hernia of seventy-five hours' duration. 
The swelling was mistaken for acute orchitis, hernia being thought of by the family 
attendant only after fecal vomiting had set in. March 19, 1887. — Herniotomy at the 
German Hospital. Extensive gangrene of the small gut was found. Ether anaesthesia 
was very bad, the patient struggling all the while during the operation. If ether was 
crowded, respiration became irregular, the face pallid, and syncope threatening. Arti- 
ficial anus was established, and the case was finished with all possible expedition, 
anaesthesia lasting altogether for thirty minutes. Deep collapse following, the patient 
did not rally in spite of copious hypodermic stimulation, and he died two hours after 
the completion of herniotomy. 

It is plausible to assume that in similar cases herniotomy performed 
with the aid of local anaesthesia would otfer better chances of success than 
if it be done in general ether or chloroform narcosis. 

The last one of the eight fatal cases died of acute septicaemia induced by 
diphtheritic enteritis of the strangulated knuckle of gut. 

Case XII. — Charles Etzler, baker, aged thirty-five. Very acute strangulation, of 
fifty hours' standing, of an old right inguinal hernia. The patient had had no medical 
care until a few hours before his admission to the German Hospital, when Dr. H. Kudlich 
was called in. He was requested to stop the violent fecal vomiting caused by a very 
large dose of Rochelle salts taken in the morning of January 31, 1884. Herniotomy on 
the evening of the same day. The large scrotal hernia contained a good-sized portion 
of adherent omentum and a massive conglomerate of several knuckles of small gut, 
bound together by firm cicatricial adhesions of old date. Free external incision of the 
abdominal wall until the neck of the hernial sac was completely divided. The gut 
looked tolerably well preserved and was replaced ; the omentum was freed by dissec- 
tion, and, being tied off in several portions, was cut off. The stump being replaced, the 
sac was tied and cut off; then the abdominal wall was sutured by several tiers of 



126 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

strong catgut in physiological order. The outer wound was drained, sewed, and 
dressed as usual. February 1st passed off without any outward symptom, the vom- 
iting having ceased immediately after the operation. February 2d. — A severe chill 
with much belly-ache set in, but no meteorism appeared until February 4th, the 
thermometer indicating all the while 105° F. The patient's condition grew steadily 
worse, with deep coma, jaundice, and petechial patches on the legs. February 5th. — 
The sutures gave way during a vomiting spell, and a loop of healthy-looking gut pro- 
lapsed. It was not replaced. Shortly after the patient died. Post-mortem examina- 
tion revealed a slaty discoloration of the mentioned bunch of coherent gut, which, 
being incised, appeared to be covered on its mucous side with a large number of round 
and confluent whitish-gray adherent patches of membrane, which involved the intes- 
tinal wall to varying depths, some of them being visible through the peritoneal 
covering. No peritonitis. 

The author is at a loss for an explanation of this rare form of diph- 
theritic affection of the bowel. 

Seven of the successful operations for strangulation were done on in- 
guinal (one preperitoneal, Case V), four on femoral, hernia. 

Cured 11 patients 

Died 8 

Total 19 

In dividing the strangulating band in femoral hernia, the incision should 
be directed inward toward Gimbernat's ligament. But, where the space is 
very narrow or the condition of the gut doubtful, free incision of the 
fascia lata parallel to the large vessels, and preparatory exposure of the 
femoral canal, would be more proper. 

To incise the strangulating bands sufficiently to enable the surgeon to 
withdraw additional portions of gut for examination does not insure facile 
reposition by any means ; and forcible crowding back of the congested and 
vulnerable intestine through an insufficiently wide orifice may lead to its 
rupture. Therefore, the dilatation must be very ample to permit easy reposi- 
tion without the use of undue force. 

As long as the sac is not closed, and communication is open with the 
peritoneal cavity, irrigation of the wound must stop, otherwise large por- 
tions of the lotion may find their way into the abdomen. The use of strong 
solutions of carbolic acid or mercuric bichloride on the prolapsed gut is 
not advisable and is unnecessary. As soon as the gut is replaced, the sac 

should be wiped clean with a disinfected sponge, 
and another small sponge, fastened to a thread of 
catgut, should be pushed into the inguinal canal 
to serve as a barrier to the influx of blood into 
the peritoneal cavity. If the patient is seen to 
bear anaesthesia well, inguinal herniotomy can be 
supplemented by the addition of Czerny's suture 
of the inguinal ring, as described under the head- 
Fig. 106.— Purse-string sut- ing of "Radical Operation of Hernia." 

are, employed for occluding ~, , n , ,-. , ... 

the neck of the hernial sac. Should, however, collapse be present or immi- 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



12' 




Fig. 107.— Herniotomy. Suture of external wound. 



Tient, and prolongation of anaes- 
thesia inadvisable, a thread of 
strong catgut is passed through 
the neck of the sac (see cut) as 
high up as possible, assistants 
holding well apart the artery for- 
ceps by which the edges of the 
cut through the sac are secured. 
This suture resembles a purse- 
string in its working (Fig. 106). 
It is tightened and knotted, and 
will securely occlude the perito- 
neal cavity. Then the external 
wound is well irrigated with cor- 
rosive-sublimate lotion, a drain- 
age-tube is placed well up to the 

purse-string suture, and the edges of the skin are brought together with cat- 
gut stitches. The dry dressings are applied so as to cover up the scrotum 

and both inguinal regions, a slit 
being left in the middle for the 
penis, which should protrude from 
the bandages. The use of a "hip- 
rest " will facilitate the application 
of the otherwise difficult dressing. 
In private practice, a common 
hassock or footstool, wrapped in 
a clean towel or slipped into a 
clean pillow-case, will make a cap- 
ital hip-rest. 

In female patients the com- 
The dressings should fit snugly, 




Fig. 108. — Yolkrnann's "hip-rest. 



presses are held down by a spica bandage 

especially about the edges, and should not be too scanty. 

Six or seven days after the op- 
eration the dressings should be 
changed, to permit withdrawal of 
the drainage-tube. Five or six 
days more will complete the es- 
sential part of the cure. 

The patient's bowels should 
be moved forty-eight hours after 
the operation by a large enema 
of soap-water. Should fever set 
in from peritoneal irritation, a 
saline purge may be administered 
with good effect. 

As long as the patient is in 




Fig. 109. — Manner of applying dressing for wounds 
of scioto-inguinal region. 



128 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



bed, nutrition should be simple and moderate. No patient should be per- 
mitted to go about his business before a truss can be 
worn with comfort. But there is no objection to his 
beiug up and about the room with 
a well-fitting pad and spica. 




Fig. 110.— Herniotomy. Patient on " hip-rest," with completed dressing. Lateral view. 

Synopsis of successful cases hitherto not accounted for : 

Case XIII. — Mrs. 0. Keinhardt, aged fifty-four, left inguinal incarcerated hernia 
of three days' duration. Operation, November 15, 1882. Cured, December 11th. 

Case XIV. — Chas. Roenscb, 
four months old, congenital in- 
carcerated hernia. Operation 
in German Dispensary, Janu- 
ary 26, 1883. Cured, Febru- 
ary 22d. 

Case XV.— G. John. See 
history, page 24. 

Case XVI. — Fred. Hipp, me- 
chanic, aged sixty, right exter- 
nal inguinal hernia. Operation 
at German Hospital, April 6, 
1884. Cured, May 1st. 

Case XVII.— Mrs. Emma T., 
aged forty-seven, left femoral 
hernia. Operation, March 25, 
1887. Cured, April 10th. 

Case XVIII. — Anna Brown, 
aged fifty, left femoral hernia, 
Operation at Mount Sinai Hos- 
pital in September, 1880. Dis- 
charged cured, end of October. 

Case XIX.— Martin Thor- 
Operation, February 12, 1880. 




Fig. ill. 



-Completed dressing of scroto-ignuinal region. 
Anterior view. 



warth, cooper, aged sixty, right inguinal hernia. 
Cured, March 5th. 



I). Radical Operation for Hernia. — In performing herniotomy for stran- 
gulation on a patient whose general condition is good, the additional steps 
for radical cure may be at once carried out to great advantage. 

In other cases of non-strangulated hernia, where retention by truss of a 
very large scrotal hernia is impracticable on account of wide distention of 






SPECIAL APPLICATION OF THE ASEPTIC METHOD. 129 

the inguinal canal, or where adhesions of the prolapsed gut or omentum to 
the sac render reduction impossible and make attempts at wearing a truss a 
torture to the patient, radical operation is proper and justified. Due ob- 
servance of the rules of asepsis makes this operation very safe as far as the 
production of purulent peritonitis is concerned. Still, some danger of 
septic infection can never be excluded with positive certainty. Therefore, 
bloody radical operation should be discouraged for a hernia that can be 
retained by a properly constructed truss. 

The author has, in the main, followed Czerny's directions in performing 
radical operation of hernia, the several steps of which are as follows : 

After due preparation by a laxative, preferably castor-oil, the patient's 
pubic region and scrotum, especially on the side of the rupture, are shaved 
and cleansed the day before the operation, with brush, soap, and hot water, 
and are wrapped up in a clean towel dipped in a three-per-cent solution of 
carbolic acid. This wet compress is again covered with a suitable piece of 
oiled silk or rubber tissue, and fastened on with a T-bandage. 

On the day of the operation the patient is placed on the table and anaes- 
thetized, a full and good anaesthesia being especially desirable. After re- 
peated disinfection, the hernial sac is exposed by a sufficiently long incision, 
in which all bleeding vessels are to be secured by ligature. The upper 
angle of the wound should be located well above the upjoer margin of the 
inguinal ring so as to permit easy manipulation. 

The sac is incised, and its edges are taken up by a number of artery 
forceps, which being held apart, an excellent view of the contents of the 
hernia can be had. Adhesions of the omentum to the sac will be found the 
most common cause of the irreponibility, the gut being rarely adherent. 
The author has observed only one case of old hernia in which adhesions of 
the gut were present (case Mau). The favorite place of omental adhesions 
is the anterior portion of the neck of the sac. 

As soon as the sac is open, the use of the irrigator has to be discon- 
tinued, to prevent entrance of large quantities of irrigating fluid into the 
peritoneal cavity. The lotions used for rinsing hands, sponges, and instru- 
ments ought to be very mild to prevent even superficial corrosion of the 
peritonaeum. The author has generally used Thiersch's boro-salicylic 
solution. 

A suitable sponge, fastened to a stout piece of silk or catgut, is pushed 
well up into the inguinal canal to prevent the entrance of blood into the 
abdomen. Care must be taken not to select a too brittle sponge, as it may 
happen that, on removing it, some portion of it may become detached and 
remain in the belly. 

The sac must be split open to within a quarter of an inch of the external 
inguinal ring, and the adherent omentum must be detached from the sac 
by preparation. As soon as the distal attachments of the omentum are 
severed, it is withdrawn a little farther from the inguinal canal, and, being 
deligated in small portions with reliable catgut, it is cut away by the knife, 
or, preferably, the thermo-cautery. After this the sac is wiped out clean, 



130 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

and, the sponge being withdrawn from the inguinal canal, the stump of the 
omentum is replaced in the abdominal cavity. 

In dissecting up adherent gut, great caution must be observed not to in- 
jure it. Where the adhesions are very close and extensive, it would be 
better to excise the attached portion of the sac with the gut, and replace 
them together in the peritonaeum. 

Case I. — Henry Mau, shoemaker, aged sixty-two. Very large scrotal hernia, con- 
taining adherent gut. The inguinal ring was so dilated that the tips of three fingers 
could easily be slipped within the abdominal cavity. February 23, 1886. — Eadical op- 
eration at the German Hospital. Ether anaesthesia produced violent retching and 
coughing, so that the irresistible escape of gut from the wound rendered operation 
impossible. Chloroform being administered, quiet anaesthesia was achieved. The ad- 
herent thick gut was dissected away, together with the adhering portions of the sac, 
and was returned to the abdominal cavity. The remnant of the sac was separated, 
closed at its neck with a purse-string suture, and was cut away. The wide gap of the 
inguinal ring was closed with eight sutures of stout catgut, and the external wound 
was drained and sewed up. Uninterrupted recovery. March 25th. — The patient was 
discharged cured with instructions to wear a light truss. In November, 1886, he pre- 
sented himself with a relapse. His truss had been broken, and he neglected to have it 
repaired. In a fit of violent coughing the rupture reappeared. 

The contents of the sac being disposed of, excision of the sac is the next 
thing to be done. 

In most cases this can be readily accomplished by stripping up the sac 
from the surrounding tissues with the fingers, the scissors being only occa- 
sionally needed to sever resisting bands, which generally contain vessels 
requiring ligature. In some instances, however, especially in cases of con- 
genital hernia, the separation of the sac is not easy. The sac proper is not 
well defined, and in some localities consists of nothing but the bare peri- 
tonaeum. Hence it is difficult to get it out uninjured and in one piece. 
Another difficulty is presented by the close relations of the cord and its 
vessels to the sac. The greatest care must be taken to properly recognize 
them, as otherwise they may be accidentally damaged. 

Case II. — William Litzebauer, baker, aged twenty-seven. Left inguinal irreducible 
hernia. February 5, 1886. — Radical operation at the German Hospital. Liberation 
of adherent omentum, which was deligated and cut away. In dissecting up the sac, 
the vas deferens was cut across. A short piece of stout catgut was introduced into the 
patent ends of its lumen, and the duct was united by four fine catgut sutures passed 
through its involucrum. The sac being removed, the external ring was closed by six 
stout catgut sutures. The external wound was drained and sewed. February 
7th. — Purulent urethral discharge was noted; no fever. February 15th. — Change 
of dressings. Wound healed by adhesion, left testicle somewhat swollen and pain- 
ful. Tube was removed. February 27th. — Urethral discharge disappeared, testicle 
notably decreased in size. March 10th. — Discharged cured, with slightly enlarged 
testis. 

Congenital irreducible hernia is comparatively frequent. Four of the 
twelve cases operated on by the author belonged to this class. One was com- 
plicated with undescended testicle. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 131 

In two of these cases castration had to be performed along with the radi- 
cal operation. 

Case III. — August B., painter, aged twenty-four. August 23, 1883. — Badical 
operation at the German Hospital. The omentum was found adherent to the left testi- 
cle, and contained near its adhesion to this organ a hard, pigmented tumor of the size 
of a walnut. The sac and the tunica propria of the testis were dotted with a large 
number of pigmented spots. Therefore the omentum, sac, and testicle were all re- 
moved. Closure of inguinal ring by catgut sutures. Treatment of external wound 
as usual. September 20th. — Discharged cured. 

Case IV. — George W., cattle-raiser, aged thirty-six. Direct inguinal hernia of 
left side, containing the undescended testicle. August 24, 1885. — Eadical operation at 
Mount Sinai Hospital. The attached omentum was freed and removed. The atrophic 
testicle was also taken away. Suture as usual. September 4th. — Patient strained at 
stool, whereupon the external wound reopened, but subsequently healed by granu- 
lation. October 2d. — Patient was discharged cured. 

In a third case of congenital hernia, in an infant, eclamptic attacks 
caused repeated protrusion of the intestine, that could not be reduced with- 
out the employment of anaesthetics. 

Case V. — Carl Schlichter, eight months old. April 18, 1886. — Prolapse of the 
gut during a convulsive seizure. Dr. Meltzer, the family attendant, administered chloro- 
form, whereupon the author reduced the gut with some difficulty. The accident had 
occurred the fourth time in spite of a truss. Eadical operation was at once performed. 
May 5th. — Patient discharged cured. 

Case VI. — Franz Faulhaber, laborer, aged twenty-two. Left congenital omental 
hernia. July 28, 1885. — Radical operation at the German Hospital. Omentum adher- 
ing to sac treated as usual. Sac was cut away below from its reflexion upon the testi- 
cle, and above close beneath the purse-string suture. Treatment of inguinal ring and 
external wound as usual. Uninterrupted cure. September 1st. — Patient was discharged 
cured. 

The closure of the sac is to be done by the purse-string suture, depicted 
by Fig. 106. Rather stout catgut must be used for this, to withstand the 
powerful tension required for closing the circular suture. The sac is cut 
away below the knot, and any bleeding vessels must be separately de- 
ligated. The stump is pushed well up within the internal abdominal 
ring. 

In applying Czerny's suture of the inguinal ring, the left index-finger 
is intruded as far as possible, its volar aspect being directed downward and 
inward to protect the cord, which should be kept near the inferior and inner 
angle of the slit of the inguinal aperture. A strongly curved needle, armed 
with stout catgut, is passed first through one, then through the other pillar 
of the ring, and the ends of the thread are secured in a pair of artery for- 
ceps, and reflected upon the abdomen, where they are received by an assist- 
ant. This first suture should be placed as high up the inguinal ring as 
possible. In intervals of a third of an inch from four to seven stitches are 
applied in the manner indicated ; then they are tied firmly by surgeons' 
knots in the reverse order. A small-sized drainage-tube is placed in the 
wound, and the integument is united by finer catgut sutures, the tube being 



132 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

brought out through the lower angle of the incision. An antiseptic 
dressing is next applied in the manner shown by Figs. 108, 109, 110, 
and 111. 

The first change of dressings should be made on the tenth day, when 
the tube is also removed. As soon as the wound is completely closed, the 
patient is permitted to get up with a spica bandage or truss. 

The patients should be directed to continue the use of a light truss, as 
this is the only reliable security against recurrence. 

In one case a fibromatous node in the adherent omentum was the chief 
source of pain complained of by the patient. 

Case VII. — Jacob Christraann, laborer, aged thirty-nine. August 15, 1885. — Radi- 
cal operation at the German Hospital. A hard, irregular node was occupying the mid- 
dle of the prolapsed and adherent omentum. It was removed with the same. Dis- 
charged cured, September 19th. The node was fibromatous in character. 

In another case a subserous fibro-lipoma was located outside of, and was 
closely connected with, the neck of the sac. 

Case VIII. — Carl Dille, laborer, aged thirty. Subserous fibro-lipoma and left 
adherent omental hernia. March 12, 1887. — Radical operation at the German Hos- 
pital. Removal of omentum and sac, together with neoplasm. Sutures as usual. April 
9th. — Discharged cured. 

The remaining four cases presented nothing unusual, and all recovered 
without mishap : 

Case IX. — Charles Niemann, locksmith, aged thirty. Adherent left omental hernia. 
February 19, 1887. — Radical operation at the German Hospital. March 12th. — Dis- 
charged cured. 

Case X. — Martin Hussmann, baker, aged twenty-five. Adherent right omental 
hernia. March 3, 1887. — Radical operation at the German Hospital. April 7th. — 
Discharged cured. 

Case XI. — Henry Mehle, barber, aged twenty-five. Adherent right omental hernia. 
January 8, 1886. — Radical operation at the German Hospital. February 12th. — Dis- 
charged cured. 

Case XII. — Mr. M. D., merchant, aged thirty-nine. Very massive, growing, adher- 
ent omental hernia of the right side. May 26, 1887. — Radical operation at Mount Sinai 
Hospital. June 16th. — Patient discharged cured. 

It has been urged, notably by Weir and Abbe, of New York, that, after 
radical operation, healing of the external wound by granulation is preferable 
to primary union, on account of the larger mass of cicatricial matter result- 
ing from the granulating process. To the author this advantage seems of 
doubtful, certainly of only passing, value, as the massive cicatrix, first hard 
and resisting, must in the course of time become atrophied, soft, and yield- 
ing, and will not be able to withstand for a long time the constant impact 
of the intra-abdominal pressure. The analogy of this fact with the experi- 
ences gathered about the wounds resulting from laparotomy can not be gain- 
said. These regularly terminate in ventral hernia when the healing of the 
abdominal incision was not by primary union, and the cicatrix produced by 
a long process of granulation is very wide and massive. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 133 

3. Laparotomy. 

a. Exploratory Incision. — Although the aseptic method has very mate- 
rially reduced the dangers of exploratory laparotomy, its wanton and un- 
necessary practice must be deprecated on several grounds. First of all, 
no surgeon is absolutely secure in his practice against accidental and un- 
expected, often unexplained, wound infection. Secondly, the dangers of 
anaesthesia, and of conditions indirectly caused by it, as nephritis, pneu- 
monia, thrombosis, and embolism, are ever present, and usually surprise 
the surgeon when least expected. 

Exploratory incision is only justified where, in the presence of a disorder 
threatening life, all known means for establishing a diagnosis have been 
exhausted without positive result, or where the extent and exact relations 
of a mechanical disturbance can not be estimated without ocular inspection 
and digital examination. 

Due observance of the rules against infection will exclude suppurative 
peritonitis with great certainty. The detail of the procedure is treated in 
the chapter on abdominal tumors. 

Case I.— Fred. Kahn, aged eleven. Intestinal obstruction of seven days' duration. 
Fecal vomiting, very great tympanites, and threatening exhaustion. No fever. June 
27, 1882. — Laparotomy under ether. In the right iliac fossa an immovable convolu- 
tion of small gut could be felt. The incision was sufficiently extended to enable the 
author to inspect the locality. It was found that the tip of the vermiform appendix 
was attached to the parietal peritonaeum. A large loop of the ileum had slipped through 
the hiatus thus formed, and was there incarcerated. The vermiform appendix was cut 
between two ligatures, and the loop of intestine became free. Seduction of the enor- 
mously distended intestines was impossible. At the suggestion of Dr. A. Seibert, an 
enema was administered, and it brought away a large quantity of gas, whereupon the 
somewhat collapsed gut could be replaced, and the abdominal incision closed. The 
operation lasted thirty minutes. Deep collapse followed, in which the patient died 
twelve hours after the operation. 

Very likely an early operation would have been followed by a better 
result. 

Case II. — Philippine Pahler, aged thirty-five. Pyloric cancer of stomach. Febru- 
ary 18, 1886. — Probatory abdominal incision at the German Hospital, with a view to 
possible resection of the pylorus. The extension of the disease to the retro-peritoneal 
glands, the pancreas, and omentum put the contemplated step out of question, where- 
fore the incision was closed. March 11th. — Patient discharged with firmly healed 
wound. 

Case III. — Albert Schroeder, painter, aged thirty. Large retro-peritoneal tumor 
located behind hepatic flexure of colon, causing intestinal stenosis. August 8, 1882. — 
Probatory incision at the German Hospital established the fact of the inoperability of 
the swelling — a sarcoma of the mesocolic glands. Closure of wound. August 9th. — 
Patient died in collapse. 

I. Abdominal Tumors : 

(a) Gexeral Remarks. — Avoidance of infection from without by scru- 
pulous cleansing and disinfection of hands, instruments, sponges, and other 
19 



134 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 112. — Ascites and ovarian tumor. Patient 
ready for operation in the lateral posture. 
Case of Dr. W. L. Estes, of Bethlehem, Fa. 



utensils should render unnecessary the application to the peritoneal cavity of 

disinfectant lotions, which, by their corrosive properties, may produce mischief. 

The usual measures adopted for protecting the body of the patient against 

wetting and undue cooling off, as the wrapping up of the extremities in 

flannels, and the spreading of rubber cloths over 
the trunk and lower limbs, leaving exposed noth- 
ing but the abdomen, demand special care and 
attention. Excessive loss of body heat is a great 

factor in determining 
collapse, and should be 
guarded against most 
sedulously. 

The principle of non- 
exposure applies equally 
to the contents of the 
abdominal cavity. The 
greater the incision, the 
more attention must be paid to the 
non-exposure of the intestines. Hot, 
flat sponges or warm towels should 
hide from view everything except 
the very spot subjected to surgical 
manipulation. 

The use of the spray apparatus during abdominal operations is harmless, 
but unnecessary. Certainly it forms a very objectionable feature of the 
original Listerian method, 
and has been abandoned 
in general as well as ab- 
dominal surgery by most 
operators. The author has 
not used the spray appa- 
ratus since 1881. 

The control of haemor- 
rhage is of the utmost 
importance to the success 
of abdominal operations. 
This and the former re- 
quirements can be best 
fulfilled by an intelligent 
observance of the rules laid 
down in the paragraphs on 
the technique of surgical 
dissection and the removal 
of tumors. The principles 
there explained remain unchanged, their application to abdominal tumors 
only being somewhat modified by the peculiarities of the locality. 




Fig. 113.— Protection of the intestines by flat sponges 
arranged about the tumor. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



135 



An ample incision is the first condition of the safe removal of an abdomi- 
nal tumor. When a unilocular, non-adherent cyst is to be exsected, a small 
incision will be ample, because the cyst, however large, can be emptied by 
tapping, and is thus reduced to the elongated proportions of a flat band, 
which can be extracted through the small incision without much force until 
the pedicle comes in view. 

Multilocular cysts that can not be emptied readily, or solid tumors, or 
growths with many adhesions, must be freely exposed, to enable the sur- 




Fig. 114.— Protection of the intestines in ovariotomy bv hot towels. 



geon to see what is to be done. Accidental laceration of the gut, bladder, 
or large veins will not easily occur while the adhesions binding the tumor 
to these organs are exposed to view. 

Disregard of this plain and rational rule is the cause of many an accident 
and mishap that might be easily avoided otherwise. 

Note. — However important the incision and final suture of the abdominal walls may be, it 
must not be forgotten that they do not represent the critical part of most abdominal operations. 
The abdominal incision, being a preliminary measure, should not occupy too much time. Of 
course, it must be done lege artis, but with expedition. Bleeding vessels need not be tied here, 
as the pressure of the hemostatic forceps, exerted for ten or fifteen minutes, will effectually 
arrest haemorrhage. Here, as elsewhere, cutting between two forceps will be more expeditious 
and safer, than the use of the grooved director. 

The skillful and unstinted use of mass ligatures by means of Thiersch's 
spindle apparatus will render the dissection even of extensively adherent 
abdominal tumors remarkably bloodless and safe. Strong catgut is prefer- 
able to silk, as the latter is known to have been the cause of suppuration in 
a good many cases, although the silk was prepared in a seemingly proper 
fashion. Extensive masses of tissue, especially if their shape approaches 
that of a membrane, should not be included in a single ligature, as they are 
very apt to slip at the edges. It is safer to divide them into a number of 
smaller portions which should be separately tied. This rule applies to the 
omentum especially. 



136 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Adhesions or pedicles of a more cylindrical shape can be safely tied in 
one mass without risking the slipping of the ligature. Every mass should 
be included in two ligatures, between which it can be severed with the knife 
or, better, the thermo-cautery. 

Transfixion of pedicles with a sharp Peaslee's needle is not advisable, as 
large veins passing into the mass may thus be cut open and cause trouble- 
some haemorrhage from a point not included in the ligature. It is better to 
use a blunt instrument, such as Thiersch's spindle, or a dressing or artery for- 
ceps, which will pass through any pedicle easily without injuring the vessels. 

Where the adhesion or pedicle is too short, and the tumor too large, to 
admit of easy manipulation under the guidance of the eye, the use of a 
temporary elastic ligature, with or without preliminary transfixion to pre- 
vent slipping, will be found a welcome expedient. To this, a rather stout, 
solid band of (not rotten) pure gum-elastic, and one or more round probe- 
pointed steel needles are necessary. The pedicle is first transfixed singly 
or crucially, then the rubber band is thrown around the needles beyond the 
place of transfixion. The ends of the tightened rubber are crossed and 
secured at the crossing by a stout pedicle-clamp. After this the tumor can 
be cut away, and the pedicle, becoming more accessible, can be divided and 
tied off with catgut in several portions. As soon as this is done the clamp 
is loosened, the rubber is removed, and the tied-off masses are trimmed and 
seared with the actual cautery. 

Close adhesions of the gut require special care. Recent adhesions are 
easily separated by blunt preparation, but cause a good deal of oozing. 
Much wiping and sponging of the oozing points is apt to prolong haemor- 
rhage, for reasons explained elsewhere. It is better to cover these points 
with a flat sponge, and to let them alone till haemorrhage ceases spontane- 
ously. The blood that found its way into the abdomen must be sponged 
out at the final toilet. Old adhesions of the intestine are very dense, and 
efforts at their blunt separation may easily lead to injury of the gut. Dis- 
section by the scalpel, the line of section being well away from the intes- 
tine, will be found the most expeditious mode of proceeding. Spurting 
vessels must be tied, and as soon as the adhesion becomes less close and 
the formation of masses by blunt separation possible, mass ligatures should 
be invariably applied. 

Forcible blunt preparation in the vicinity of large veins, more especially 
of the large plexus regularly encountered in the bottom of the small pelvis 
near the uterus and its adnexa, is hazardous, on account of the haemorrhage 
often caused by laceration of the delicate walls of these vessels. Careful 
isolation and double deligation, with subsequent cutting between the liga- 
tures, are the best safeguard against dangerous haemorrhage. 

Blunt dissection, preferably by the tips of the fingers, is, however, emi- 
nently proper where the peritonaeum is to be stripped up from underlying 
tissues. It is, in fact, the only safe way of separating tumors that are 
located between the folds of the broad ligament, in the mesentery, or in 
any portion of the retro-peritoneal space. 



SPECIAL APPLICATION 'OF THE ASEPTIC METHOD. 137 

Exploratory puncture and aspiration of exposed abdominal cysts of un- 
known contents with a fine, hollow needle is very advisable, as the exact 
knowledge of the nature of the cystic contents may materially modify sub- 
sequent steps of the operation. 

If the cystic fluid be bland, its escape into the peritoneal cavity does not 
signify much, provided that careful cleansing be employed before the clos- 
ure of the wound. But when the cyst contains purulent or fetid serum, 
accidental soiling of the peritonaeum by it may effectually destroy all chances 
of recovery. 

Whenever puncture of an exposed tumor is determined on, whether by 
a small or large-sized instrument, good care must be taken to prevent, dur- 
ing and after the act, the escape of cystic fluid through the puncture-hole 
into the abdominal cavity. To do this it is necessary to surround the 
needle or trocar with a number of flat sponges laid on the tumor. As soon 
as the piston is withdrawn the nature of the fluids appearing in the barrel 
of the syringe will become manifest. If it be clear and limpid, no further 
precaution need be taken. Should the fluid appear to be turbid, or mani- 
festly purulent, the barrel should be emptied and refilled and emptied again, 
until the tension of the sac becomes so far reduced, that its transfixed portion 
may be raised in a fold and secured by a large clamp. The sponges used 
for this step of the operation should be at once discarded. 

To prevent laceration of the sac or capsule, the utmost gentleness and 
care should be practiced in handling the tumor. The use of sharp re- 
tractors and vulsellum forceps, or forcible traction with or without blunt 
force of any kind, are extremely ill-advised. Not only may the sac be 
torn, but large veins spread out over the surface of the tumor may be in- 
jured, and give rise to uncontrollable haemorrhage. The aperture of a torn 
vein can not be easily occluded by any kinds of artery-clamp, first, because 
of its irregular shape and extension, and principally because the tension of 
the capsule of a solid tumor precludes the formation of a fold that could be 
conveniently grasped. 

Note. — The author recalls an instance witnessed by him where, during the removal of a 
large uterine growth through an inadequate incision, sharp retractors were used in forcibly 
developing the mass from the abdominal cavity. Several large veins being torn, profuse haem- 
orrhage set in. The incision was somewhat, but still insufficiently, enlarged, and, more force 
being applied, the tumor was finally brought out of the abdomen. But very soon it became evi- 
dent that, in consequence of the forcible manipulation, the transverse colon, which was closely 
adherent to the posterior aspect of the tumor, had been extensively torn. Enterorrhaphy did not 
save the patient's life, which was forfeited by the injudicious management induced by super- 
stitious fear of a " large " abdominal incision. 

The tenet of making small incisions for the removal of abdominal tumors 
had its origin in the justified disinclination to expose a large peritoneal sur- 
face to the contaminating and refrigerating effect of the atmospheric air. 
And unnecessarily long incisions are certainly to be avoided. But the sur- 
geon's discretion must decide the question of the size of the incision, the 
principle of safe dissection under the guidance of the eye being herein of 
the first importance. 



138 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Undue cooling off of the peritonaeum is a very undesirable thing, on 
account of the collapse it may induce ; therefore, all portions of the abdomi- 
nal organs that are not actually under dissection should be carefully covered 
up by large flat sponges or clean towels wrung out of hot Thiersch's solution. 

Note. — To always have a sufficient supply of warm sponges and towels, the following 
arrangement will be found convenient : A tin pan or basin, containing the sponges or towels 
immersed in Thiersch's solution, is rested on the tops of two clean bricks stood on edge. A 
blazing alcohol-lamp is placed between the bricks and underneath the vessel, which, being cov- 
ered with another pan, will preserve unchanged the temperature of its contents. For larger 
operations, three or four similarly prepared pans can be conveniently arranged on a separate 
table. 

Whenever a stout adhesion or a pedicle is deligated and cut through, 
it should be dropped back into its natural position, where it should be 
inspected for a short while to see whether haemorrhage is thoroughly con- 
trolled by the ligature. Oozing points should be touched with the thermo- 
cautery, but care must be taken not to go too near the ligature, for fear of 
burning it. 

Oozing points located on the gut should never be touched with the 
thermo-cautery. 

It is best not to tap at all dermoid cysts or tumors containing clearly 
septic fluid, as the integrity of the cyst-wall is the only guarantee of pre- 
venting contamination of the abdominal cavity by cystic fluids. Rather 
increase the external incision, and remove the tumor intact. 

The relations of the bladder to the tumor should be carefully considered. 
Greig Smith advises not to empty the bladder before operation, and it is 
undeniable that a full bladder can not be well overlooked or injured. In- 
jury to an empty and collapsed bladder, on the other hand, has repeatedly 
occurred in the presence of abnormal adhesions of the organ to the tumor. 
To further ascertain the extent of adhesions of the bladder, the introduc- 
tion and manipulation of a solid male urethral sound will be found very 
useful. 

Note. — Catheterism should be done, if possible, by a person not employed about the 
wound, or, if this be not feasible, careful cleansing and disinfection of the hands should follow it. 

After the removal of the tumor, the toilet or cleansing of the abdominal 
cavity has to be attended to. Sponges attached to long handles are very 
convenient for this purpose. With them first the lumbar, then the vesico- 
uterine recesses, finally the utero-rectal or Douglas's pouch, are to be thor- 
oughly cleansed and dried. 

In the presence of large denuded surfaces lacking peritoneal investment, 
a glass or hard-rubber drainage-tube is to be inserted into the bottom of 
the small pelvis. It can be brought out through a counter-opening made 
into the vagina from Douglas's pouch, or through the lower angle of the 
abdominal incision. 

In the former case, the external end of the tube projecting into the 
vagina or in the vulva must be wrapped in a packing of iodoformized 
gauze, which ought to be changed whenever it gets saturated. When the 



SPECIAL APPLICATION ' OF THE ASEPTIC METHOD. 



139 



tube is brought out through the abdominal incision, its outer end must be 
so dressed as to be easily accessible. Every hour the serum collecting in 
its bottom should be exhausted with a pad of absorbent borated cotton fixed 
to a handle, or with a long-nozzled syringe. In the intervals the tube should 
be covered with a moist pad of sublimated gauze. As the serum diminishes, 
this process is gone through with at longer intervals. As soon as the tube 
remains dry for several hours, generally about the third day, it can be with- 
drawn. 

Note. — Miculicz has successfully substituted for the drainage-tube a loose packing and fillet 
of iodoformized gauze, brought out through an angle of the wound. The exsiccation of the secre- 
tions by this arrangement is certainly very effective, as seen in several cases reported by Dr. F. 
Lange. The fillet should be removed on the third or fourth day. 

The closure of the abdominal wound should he done as rapidly as thor- 
oughness will permit, simplicity and solidity of the suture being the main 
desiderata. 

A Peaslee's needle is thrust on one side through the entire thickness of 
the abdominal wall, including the peritonaeum, and is brought out in a 
similar manner on the other. The points of entrance and emergence should 
be at least two inches from the edges of the wound. A piece of well-disin- 
fected silver wire or stout silk-worm gut, armed with a quill, or a leaden 
plate and shot, is threaded through the eye of the needle. This is then 
withdrawn, bringing out the end of the thread from one side of the 




Fig. 115. — Completed quilled suture of abdominal incision. 

wound to the other, where it is temporarily secured by an artery forceps. 
Three, four, or more retentive sutures of this kind are passed at intervals of 
about an inch, until the entire length of the wound is covered by them. 

Note. — While the stitches are being passed, a flat sponge should be kept spread over the 
intestines to receive the blood escaping from the stitch-holes. 

If the patient's condition be good, the peritonaeum may be separately united by a row of 
catgut sutures placed between the silver or silk-worm gut stitches. But this is not essential. 



140 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 116. — Completed plate and shot suture of abdominal wounds. 



After the withdrawal of the flat sponge, and a final cleansing of the peri- 
tonaeum by sponges fixed to long handles, a quill is applied to the unarmed 

end of the thread, and 
is tightened until the 
edges of the incision 
are raised in the shape 
of a low ridge. Or, 
if lead plates are to be 
used, one of these is 
slipped on the thread 
with a perforated shot, 
the thread is tight- 
ened, and the shot is 
pinched. After this, 
a sufficient number of 
exact "sutures of co- 
aptation," made of fine 
catgut, secure the edges 
of the incision. (Figs. 
115 and 116). 

The dressings con- 
sist of a few strips of iodoform-gauze, and an ample compress of sublimated 
gauze over it, all snugly fastened by several strips of adhesive plaster and a 
broad flannel or gauze bandage. 

On from the eighth to the tenth day the dressings are changed, and the 
retentive sutures are removed ; but the bandage must be worn for some 
time to serve as a support to the fresh cicatrix. 
(i) Special Obsekvatio^s : 

a. Ovarian Tumors. — Probatory puncture of an abdominal tumor 
through the walls of the belly is not an indifferent matter. If the tumor be 
cystic, and its wall very tense, escape of a limited quantity of cystic contents 
is unavoidable. Bland and very thin contents may escape in large quantities 
without causing irritation. A large number of cases are on record in which 
probatory puncture of cysts of the broad ligament was followed by cure. 

Case. — Mrs. Francisca N"., liquor-dealer's wife, aged thirty-four, was tapped, 
August 31, 1877, for a large abdominal cyst. About a gallon of fluid, characteristic of 
a cyst of the broad ligament, was removed, but a considerable quantity was left behind. 
In a short time the flabby, fluctuating swelling disappeared entirely, and the woman 
remained free from any further trouble. 

Escape of minute portions of purulent cyst-fluid is apt to cause circum- 
scribed peritonitis, resulting in more or less extensive adhesions. Larger 
quantities of septic matter, that find their way into the peritoneal cavity, 
may produce fatal purulent peritonitis. 

The preparations, with a view to the aseptic performance of exploratory 
or evacuating puncture, must be very thorough, as the use of an unclean 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 141 

needle or trocar may be the source of peritonitis or suppuration of the sac. 
The hollow needle or trocar to be used must be sterilized either by boiling 
for an hour in a five-per-cent solution of carbolic acid, or by incandescence 
in the alcohol-flame. 

When an exposed cyst is to be tapped or emptied by incision, the patient 
should be turned over on her side. An assistant should prevent the escape 
of gut ; another one should surround the place of tapping with a circle of 
sponges to receive fluid that may escape alongside of the instrument. Tait's 
trocar is, on account of its simplicity, the best one of all instruments devised 
for evacuating cysts. 

As soon as the cyst begins to collapse, its folds should be taken up with 
large clamps. The empty cyst is then withdrawn to the pedicle, which is 
tied in one or more portions and cut off. 

Case I. — Mrs. Dorothy Grunewald, aged sixty-one, multipara. Unilocular cyst of 
the left ovary. December 19, 1882. — Ovariotomy. External incision four inches long. 
Cyst presenting, patient was brought in lateral position. Tapping, evacuation, and 
extraction. Kather stout pedicle transfixed with thumb- forceps, and tied in four por- 
tions, then cut off and dropped back into the abdomen. Uninterrupted recovery. 
January 4, 1883. — Discharged cured. 

Multilocular cysts can be best emptied by making a free incision through 
their presenting part, through which the hand can be carried within the 
tumor to break up intervening septa. All this should be done extra-peri- 
toneally if possible. 

When a cyst is found extensively adherent, its contents should be care- 
fully mopped out with a sponge, and the interior of the sac should be dis- 
infected while the patient is in the lateral posture. After this a large sponge 
is thrust into and left within the cavity until the cyst is dissected out. 

Case II. — Miss Lucretia Bernard, aged seventy-two, virgin. Very large multilocu- 
lar ovarian cyst of the right side, causing intense dyspnoea. August 8, 1881. — Punct- 
ure and partial evacuation at Mount Sinai Hospital, resulting in marked relief of the 
dyspnoea. August 10th. — Fever set in, with some abdominal tenderness, and suppura- 
tion of the cyst was apprehended. August 13th. — Ovariotomy. Incision twelve inches 
long. Broad, recent adhesion of the sac to the anterior abdominal wall severed by 
blunt preparation. Patient being brought into the side position, the cyst was first 
tapped, then incised, and its volume was much reduced by breaking down septa by the 
hand. Some haemorrhage occurring, a large sponge was thrust into the sac, and the 
patient was returned to the supine position. A number of adhesions to the right side 
of the parietal peritonaeum and ascending colon were divided between several double 
mass ligatures of silk. Short pedicle was similarly secured. Toilet of peritonaeum ; 
closure of incision. Moderate elevations of the temperature. Uninterrupted healing 
of wound. November loth. — Abscess of right groin was incised. Three silk ligatures 
were discharged. August 11, 1882. — Patient died of an intercurrent disease not con- 
nected with ovariotomy. 

Case III. — Mrs. Lena Dochtermann, aged thirty-nine, multipara. Very large 

multilocular cyst of right ovary. General condition very poor; chronic bronchial 

catarrh and chronic enteritis, with diarrhoea, ascites, and anasarca. April 19, 1886. — 

Ovariotomy. Extensive adhesions of cyst to anterior and lateral parietes ; to transverse 

20 



142 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



colon, omentum, and the bladder. A large number of mass ligatures were made. 
Haemorrhage insignificant. Duration of operation two hours and a half. Patient died 
in collapse seven hours after the completion of the operation, temperature remaining 
subnormal to the last. 

Cysts of the broad ligament generally present great difficulties on account 
of their situation between the peritoneal folds of the ligament. If they 
extend low down into the small pelvis, their dissection is occasionally im- 
practicable, and always very difficult. The utmost circumspection and care 
must be exercised not to provoke haemorrhage by injuring large veins in the 
bottom of the wound, and all adhesions, not yielding to gentle blunt dissec- 
tion with the fingers, must be fashioned into suitable masses, doubly tied 
with Thiersch's spindles, and then divided. In cases baffling the skill or 
enterprise of the surgeon, the sac should be properly trimmed and stitched 
to the skin, so as to convert it, if possible, into an extra-peritoneal recess. 
Drainage of the sac is indispensable. 

Case IV. — Mrs. Ethel D., aged twenty-one, nullipara. Eather immovable cyst of 
the right broad ligament of the size of a child's head. April 6, 1887. — Ovariotomy. 
Incision five inches long. The cyst had dissected its way out from between the folds 
of the broad ligament, and had pushed away the parietal peritonaeum of the anterior 
abdominal wall on the right side to such an extent as to remain entirely extra-peritoneal. 
The sac was tapped and emptied, then it was easily separated from its attachments by 
blunt preparation. About one fourth of a square foot of peritonaeum was detached. 
Finally, the pedicle was reached, secured in three ligatures carried through by means 
of Thiersch's spindles, tied, and cut off. The cavity was mopped out with corrosive- 
sublimate lotion, drained by two ordinary rub- 
ber tubes, and the external wound united and 
dressed in the usual manner. April 7th. — 
Nothing alarming had occurred, the tempera- 
ture ranging about 99° Fahr. April 8th. — 
Temperature 101*5° Fahr., with a good deal of 
tympanites and dyspnoea. Pulse of varying in- 
tensity and rhythm, about 125 beats per minute, 
and rather weak. The outer bandage had to be 
loosened, and energetic stimulation by hourly 
enemata, consisting of one ounce of brandy and 
two ounces of warm water, were administered, 
till the pulse became decidedly fuller and more 
regular. April 10th. — Some flatus passed spon- 
taneously, the meteorism diminished markedly, 
and the temperature fell to the normal standard. 
April 11th. — Patient consumed a few oysters 
and a little champagne, her nourishment hav- 
ing consisted until then of milk and lime-water. 
On the same date slight uterine and vesical 
haemorrhage was noted. The former may have 
been dependent upon subinvolution remaining behind after a recent miscarriage ; the 
vesical haemorrhage seems to have been due to detachment of the superior and lateral 
vesical wall during dissection. April 13th. — A saline laxative was administered, caus- 
ing some nausea and vomiting with a good deal of griping, but resulting in three copi- 




Fig 



117. — Diagram of cyst of the broad 
ligament. (Case IV.) 



SPECIAL APPLICATION' OF THE ASEPTIC METHOD. 143 

•ous stools. The same day the drainage-tubes were shortened. The wound was found 
healed by adhesion except where the tubes lay. Three of the plate and shot sutures 
were also removed, and two were left behind. The catgut sutures had been all ab- 
sorbed. April 18th. — The tubes were entirely withdrawn and remaining sutures 
removed. April 20th. — The patient left the bed. the first time. April 25th. — The 
wound was entirely healed. (Fig. 117). 

It seems that the extensive detachment of the peritonaeum from its 
nutrient vessels led to a grave disturbance of its circulation, and perhaps to 
partial {aseptic) necrosis. An adhesive peritonitis of the intestinal invest- 
ment apposed to the denuded parietal peritonaeum was set up, causing 
paralysis of the muscular layer of the gut with meteorism. As soon as the 
devitalized parts of the peritonaeum were enveloped by fresh exudations, the 
irritation ceased. 

p. Supra-vaginal hysterectomy for large myo-fibroma of the uterus may 
he indicated either by profuse loss of blood at the menstrual epoch, or by 
other causes rendering the patient's life unendurable. An operation should 
be determined on only, after a faithful trial of less incisive remedies known 
to induce involution of uterine fibromata, has plainly failed to give relief. 

The preparations for the operation are to be made with all possible care, 
directed to the avoidance of septic infection. Haemorrhage is to be pre- 
vented by the application of single or double mass ligatures to the uterine 
adnexa on both sides 
of the uterus, and 
a stout elastic cord 
to the cervix. Un- 
der favorable condi- 
tions (that is, when 
the- cervix forms a 
slender pedicle to the 
otherwise movable 
womb), the applica- 
tion of double liga- 

, , , . , Fig. 118. — Diagram showing the arrangement of mass ligatures in 

tures Can be Obviated supra- vaginal hysterectomy. 

by cutting off the 

blood-supply of the organ from all sides by two continuous lines of mass 
ligatures converging from the free margin of the adnexa toward the cervix. 
A suitable-sized mass is first formed at the margin of the broad ligament by 
means of Thiersch's spindle, and is tied off with strong catgut or silk. A 
second mass adjoining the first one is now isolated, and the thread being- 
carried around it and back through the aperture made for the ap}3lica- 
tion of the first ligature, is firmly knotted. A third mass is isolated by 
Thiersch's spindle, and the thread is carried back through the hole made 
for the isolation of the adjacent mass, and the application of the preceding- 
ligature. Thus the cervix will be soon reached. While an assistant raises 
the tumor well above the pelvis, an elastic ligature is thrown around the 
elongated cervix ; being tightened, it is secured by a stout pedicle-clamp. 





144 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

This step will have completed the isolation of the uterus, which can be now 
exsected without loss of blood, the line of section being carried just outside 
of the chain of ligatures. (Fig. 118.) 

The uterine stump must not be cut oif too short, as it is desirable to 
retain sufficient material for covering up its raw surface with peritonaeum. 
The cervical canal is to be burned out thoroughly with the thermo-cautery, 
to destroy any septic material contained in it. After this, the cut surface 
of the uterine stump is hollowed out with the scalpel in the shape of a cup, 
its center being located in the cervical canal. This is done until the edges 
of the cut can be folded upon each other, when they are united with a 
sufficient number of deep, intermediate, and superficial catgut sutures. 
The deep sutures are to be applied with a large curved needle, that should dip 
down to the level of the elastic ligature. The intermediate sutures should 

reach to about one half of the depth of the stump ; 
the superficial stitches are to hold together the 
peritonaeum. Thus exact coaptation of the entire 
Hi ( i !T1" 11x11 "l H 'T' IT/ cu ^ sur f ac8 °f the uterine stump is brought about, 
\£ \ A | A i and it serves two good purposes : First, the elas- 

tic ligature can be removed without fear of pro- 
Fig. 119.— Suture of uterine fuse haemorrhage. Any oozing between the stitches 
&etmV S Tschr™ie^) can be controlled by 'sponge pressure till a clot is 
formed within the wound. The second advantage 
is the exclusion of all communication between the vagina and cervix on one 
side, and the peritoneal cavity on the other. (Fig. 119). 

Where the pedicle is short and very stout, slipping of the elastic liga- 
ture must be prevented by crucial transfixion of the cervix with a pair of 
large and well-disinfected shawl-pins. These can be removed, together 
with the rubber cord, after the completion of the suture of the stump. 

In the presence of adhesions, or a broad implantation of the myoma into 
the deeper parts of the pelvis, the same rules of dissection are to be heeded 
that have been elucidated in a former paragraph relating to abdominal tumors. 

The author's only case of supra-vaginal hysterectomy ended fatally by 
septicaemia. The sources of infection were presumably the sponges, man- 
aged by two raw members of the training-school for nurses at Mount Sinai 
Hospital. 

Case. — Mrs. S. Levy, aged thirty-three, multipara. Very large fibro-myoma of the 
corpus uteri. Severe metrorrhagia at each menstruation, with increasing anaemia and 
great helplessness from the.size of the tumor. June 7, 1883. — Hysterectomy at Mount 
Sinai Hospital. Incision six inches long. Easy deligation of adnexa in two rows of 
mass ligatures ; elastic ligature of cervix; ablation of the tumor and adnexa. Searing 
of the surface of the small stump by therm o-cautery. The smallness of the stump 
induced the author to treat it like an ovarian pedicle, and it was replaced in the abdomi- 
nal cavity after securing of the elastic ligature by a knot of strong silk. Hardly any 
blood was lost, and a smooth course of healing was expected. But all hopes were 
shattered by the development of septic symptoms in the night following the operation. 
June 8th. — High fever, retching, and sharp abdominal pain were present, but no signs 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 145 

of peritonitis could be made out. Twenty-nine hours after the operation the patient 
died in coma. Post-mortem examination revealed an abscess of the abdominal wall in 
the line of suture, and a grayish discoloration of the peritonaeum near the elastic liga- 
ture. A few drachms of turbid, bloody serum were found in Douglas's pouch. No 
sign of peritonitis. 

Investigation showed that during the operation the management of the 
sponges by the nurses had been a careless one ; that a too large number of 
persons were intrusted with the care of the sponges. The practical out- 
come of this experience was the order, that the sponges should be attended 
to by one person only, and that this person should always be the most 
experienced and responsible one of the available number. 

The preceding case shows that fatal septicaemia may be induced by infec- 
tion of the peritonaeum, and yet purulent peritonitis may be absent. Per- 
haps there was not enough time for the development of peritonitis. 

Many rapidly fatal cases, classed by various surgeons under the heading 
of "shock" or "exhaustion," zvould, on closer inquiry, turn out to he cases 
of acute septicemia. 

y. Nephrectomy by abdominal section is clearly justified in cases of de- 
generated movable kidney when the urine gives sufficient evidence of chronic 
pyonephrosis with or without stone. 

Case. — Mrs. S. Weissen stein, aged forty-six. Noticed fourteen years ago a mova- 
ble painless lump in her right hypochondrium. Since about nine months very acute 
symptoms of cystic trouble set in, and the lump became larger and painful. Constant 
desire to urinate, continuous fever, with occasional rigors, and large quantities of pus 
in the urine brought her to a very low state. A smooth, hard, kidney-shaped movable 
tumor of the size of a large man's fist could be felt in the right hypochondriac region. 
January 11, 1887. — Examination under chloroform. The left Mdney could not oe 
made out distinctly. The urine was scanty and acid, amounting to about twenty ounces 
per day, of the consistency of cream, and contained very large quantities of pus. Janu- 
ary 15th. — Abdominal nephrectomy at the German Hospital. The tumor being ex- 
posed, the hand wasjslipped into the left lumbar part of the peritoneal cavity, when 
the left Mdney could oe distinctly felt. After this the peritonaeum and its capsule were 
split along the whole anterior aspect of the enlarged kidney, and the organ was easily 
peeled out. A pedicle was formed of the ureter and vessels, and was tied off in two 
masses. After the removal of the tumor, the large retro-peritoneal cavity was carefully 
mopped out and loosely packed with strips of iodoformed gauze. These were brought 
out near the upper angle of the abdominal wound. The edges of the incision through 
the posterior lamella of the peritonaeum and the renal capsule were stitched to the 
peritoneal lining of the anterior abdominal wall. The outer wound was united in the 
usual way. The patient lost very little blood, but during the operation threatening 
heart- weakness necessitated the subcutaneous exhibition of camphor and whisky. She 
rallied pretty well, and passed some perfectly clear urine shortly after the operation. 
January 16th. — Temperature, 100° Fahr. Patient cheerful, and suffering very little 
pain. Urine continues clear and very concentrated. In the night several fainting- 
spells. The night nurse did not pay sufficient attention to the patient, who died in a 
fit of syncope early in the morning of January lTth. Post-mortem examination failed 
to show any morbid change aside from the abdominal wound, which was found dry, 
and just as fresh as at the time of the operation. With more untiring stimulation, the 



146 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

patient might have survived. The enlarged right kidney had lost its textural charac- 
ter, and was converted into an irregular sinuous bag, containing six uratic stones of 
various sizes. 

c. Gastrostomy. — Impassable cicatricial stenosis of the oesophagus is a 
very strong indication for the establishment of a gastric fistula. Threat- 
ening starvation will be thus averted, and an opportunity will at the same 
time be created for attempting retrograde catheterism of the oesophagus, 
which may succeed. 

Case. — Hedwig Meyer, aged twenty-four. Cicatricial impassable stricture of the 
oesophagus twelve inches from incisors, caused by swallowing pure carbolic acid. 
Liquids only could be swallowed, with frequent regurgitations. Extreme emaciation. 
April 17, 1886. — Gastrostomy at the German Hospital. Immediately below and par- 
allel with the left costal arch, an incision of two and a half inches exposed the perito- 
naeum. After stanching the slight haemorrhage, the peritonaeum was incised, and 
the edges of the peritoneal incision were taken up by four artery forceps. The left 
lobe of the liver was found presenting. This being pushed aside, the anterior wall of 
the empty stomach came in view, and was withdrawn from the wound with a pair of 
thumb-forceps. The cardiac portion of the organ was drawn well into the wound, and 
was transfixed with a Peaslee's needle to prevent its slipping back. The peritoneal 
covering of the stomach was stitched to the everted edges of the parietal peritonaeum 
by two tiers of interrupted silk sutures. The artery forceps were of very great service 
in securing the apposition of broad peritoneal surfaces. The external wound was 
packed with iodoformized gauze, and dressed antiseptically. No reaction following, 
the packing was removed on April 20th, and the Peaslee's needle was withdrawn. 
After this an incision one half inch long was made into the stomach, and a short piece 
of stout drainage-tube snugly fitting into the aperture was placed in the stomach, and 
was secured from slipping in by a large safety-pin. Its opening was closed by a cork 
stopper. Previous to this the lips of the mucous membrane were stitched to the outer 
skin. From this date on daily attempts were made to pass the stricture with a sound, 
introduced into the oesophagus from below, through the gastric wound. May 13th.— 
Dr. Bachmann, the house-surgeon, succeeded in passing from below an elastic catheter 
armed with a mandrel through the stricture. Milk injected into the catheter made its 
appearance in the fauces. May lJ^th.- — A small-sized sound was passed from above. 
Alimentation was carried on both artificially through the drainage-tube placed in the 
stomach, and by the mouth. Gradually, as the ability to swallow solids returned, more 
and more food was taken by the mouth, and the drainage-tube was withdrawn from 
the stomach. The gastric fistula closed spontaneously by the end of June. August 
26th. — Patient was discharged, with directions to continue the use of the oesophageal 
bougie. 

In cases of cancer of the oesophagus, gastrostomy does not yield favorable 
results. Of six cases, mostly men past middle age, and all presenting the 
picture of more or less extreme emaciation, five died in a few (all within 
twelve) hours after the operation. The slight depression of the heart's action 
by anaesthesia was sufficient to induce fatal collapse. The sixth case sur- 
vived the operation for thirty-two days, but was losing ground steadily in 
spite of artificial feeding by the tube placed in the stomach. A great deal of 
difficulty was experienced in this case on account of the considerable leakage 
that was taking place alongside of the tube. Apparently the incision had 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 147 

been made too large, and gastric juice was escaping in varying quantities 
into the dressings. The gradual emaciation and final dissolution were in a 
great measure due to this constant loss of albuminoid substances. 

The outer dressings of a gastrostomy wound are arranged in the follow- 
ing manner : A split compress of iodoform ized gauze, similar to that used 
in tracheotomy dressings, is slipped in under the safety-pin holding the 
drainage-tube, and is arranged around the same. A piece of rubber tissue, 
or sheet rubber, somewhat larger than the gauze compress, is provided with 
a not too large slit in its middle, which then is also slipped on the end of 
the tube by being passed first over one, then over the other end of the pin. 
The rubber should fit snugly to the tube. Over this is laid a succession 
of two or more sublimate-gauze compresses of increasing size, each pro- 
vided with a slit for the passage of the corked-up end of the rubber tube. 
The safety-pin, which was underpadded by the iodoformed gauze and rub- 
ber sheet, is covered up by the subsequent compresses, which are snugly 
bandaged to the trunk. Over the outer bandage another apron of rubber 
tissue is pinned, the rubber tube projecting from a slit in its middle. The 
object of this is to protect the bandage from soiling by regurgitant food. 

Feeding is to be done at first in short intervals ; later on, larger quan- 
tities of food can be introduced m four daily doses. 

d. Colotomy. — Rectal obstruction, most commonly by syphilis or cancer, 
is an accepted indication for the establishment of an artificial anus, either in 
the groin or in the loin. Lumbar and inguinal colotomy each has special 
advantages and drawbacks, the consideration of which must determine the 
choice of the method preferable in a given case. While lumbar section is 
extra-peritoneal, nevertheless injury to the peritonaeum is very apt to occur; 
finding of the colon is not easy ; sometimes it is impossible without opening 
the peritonaeum, notably when there is a well-developed mesocolon. The 
shape of the artificial anus after the lumbar operation is mostly excellent on 
account of the ample mass of tissues traversed by the fistula ; but the situa- 
tion of the aperture is unhandy, the patients generally requiring the aid of 
a second person for cleaning and dressing the artificial anus. 

Inguinal colotomy is a short and easy operation, and provides for an 
opening located accessibly for the manipulations of the patient in cleaning 
and dressing the aperture. Its drawbacks are the necessity of incising the 
peritonaeum — a circumstance which has lost most of its terrors since the in- 
troduction of the aseptic method — and the tendency to troublesome prolapse 
of the intestinal mucous membrane. The latter difficulty can be overcome 
by a discreet proportioning of the external and intestinal openings. 

(a) Lumbar colotomy. — Finding of the posterior aspect of the colon is 
very much facilitated by insufflation of the thick gut. This can be done 
either by a bellows attached to a soft catheter passed in beyond the stricture, 
or by the similar employment of a siphon bottle filled with mineral water 
charged with carbonic acid. The mouth of the siphon is connected with 
the catheter by a piece of rubber tubing, then the siphon is inverted and 
the valve is opened. The carbonic-acid gas, collecting about the end of the 



148 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

glass tube reaching to the bottom of the bottle, escapes into the gut, and pro- 
duces a visible bulging of the colon. 

When the stricture is impassable and inflation not practicable, recogni- 
tion of the colon may offer great difficulty. The landmarks are the kidney 
above, and the reflexion of the peritonaeum externally, but occasionally they 
are of little practical use. 

Case I. — Mrs. C. O., aged fifty-six. Very extensive far-gone cancer of the rectum 
with involvement of the uterus. The stricture was very long and impassable. June 25, 
1882. — Lumbar colotomy was attempted. Though the kidney and the reflexion of the 
peritonaeum were clearly discerned, the incision opened the peritonaeum, and the pro- 
truding gut turned out to be small intestine. The poor condition of the patient made 
further prolongation of anaesthesia undesirable, therefore the gut was attached to the 
skin and incised. The wound healed promptly, giving much relief, but the patient 
died four weeks after the operation from emaciation, due in part to insufficient nutri- 
tion caused by the high position of the intestinal aperture. Post-mortem examination 
showed that the intestinal fistula was midway between the stomach and caecum. 

Case II. — Mrs. Mary Brunner, aged forty-three. August 23, 1885. — Lumbar coloto- 
my at Mount Sinai Hospital under ether. August 2J^th, 25th. — Acute lobar pneumonia 
of the entire right lung, to which the patient succumbed. The colotomy wound had 
closed by primary adhesion. Presumably the pneumonia was caused by the entrance 
of foul oral secretions into the right bronchus during the operation. 

(b) Inguinal colotomy. — A vertical incision is preferable to one parallel 
with Poupart's ligament. With the former, the fibers of the oblique 
muscles will be cut across their course and will retract, giving ample space 
for a clear insight and free manipulation. Asepticism has to be maintained 
as in all abdominal operations mainly by scrupulous cleanliness. 

The peritonaeum is sufficiently incised to grasp the presenting colon with 
the fingers for withdrawal, and its edges are secured with four artery -forceps. 
The gut will be known by its taeniae and the epiploic appendices. A loop 
about two inches in length is withdrawn, and its mesial and distal halves are 
stitched to each other in front and in the rear so as to cause the formation 
of a spur (a b, Fig. 120). The sutures are made with an ordinary straight 
sewing-needle, the suturing material being catgut No. 3. 
The stitches should include only the peritoneal covering 
of the intestine. The loop is then dropped back into the 
peritoneal incision, and its apex is stitched to the parietal 
peritonaeum all round with two tiers of catgut sutures. 
In doing this the parietal peritonaeum can be well everted 
by the artery-forceps attached to it, and a broad surface 
Fig. 120. — Forma- of contact between it and the gut can be thus secured. 
ffuinai coFotomy 1 " Finally, the gut is incised and the intestinal mucous mem- 
brane is sewed to the outer skin. To prevent prolapse of 
the mucous membrane, or leakage, the incision should not be made too 
large. The formation of the spur as suggested by Verneuil has this advan- 
tage, that fecal matter will not find its way into the lowest part of the 
rectum situated below the artificial anus, and thus painful and otherwise 
disagreeable regurgitation of faeces will be avoided. At the same time, secre- 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 149 

tions forming in the distal section of the rectum will not he retained, but 
can escape through the fistula. 

The proposition of completely dividing the loop of extracted colon, sew- 
ing the upper end into the wound, and closing by suture and dropping back 
the distal end, is feasible, but is met by a serious objection. The stricture 
may lead to complete occlusion, and the secretions of an ulcerated cancer 
may so distend the closed gut as to lead to rupture of the sutured part and 
to fatal peritonitis. 

Case I. — Mary Steiger, aged fifty-nine. Extensive rectal cancer with a number of 
periproctitic abscesses causing profuse purulent discharge through the anus. Emaciat- 
ing hectic fever and distressing fecal retention. August 13, 1885. — Inguinal colotomy 
at the German Hospital. The thick gut was withdrawn, and was closed with two 
ligatures of stout silk carried through the mesocolon by the point of a thumb-forceps. 
The peritoneal incision was covered with two flat sponges and the gut was cut through 
between the ligatures. A little fecal matter escaped and was caught by the sponges, 
whereupon they were changed. The open lumen of the gut was mopped out cleanly, 
and well irrigated with Thiersch's solution. After this the distal end of the gut was 
closed by two tiers of Lembert sutures made with catgut, and was returned to the 
abdominal cavity. The peritoneal layer of the mesial end was stitched to the parietal 
peritonaeum and the mucous membrane to the outer skin. The patient rallied well 
from the operation, but the high fever and profuse discharge from the anus continued. 
August 18th. — The patient died under septic symptoms. On autopsy, the wound was 
found healed by the first intention, likewise the sutured distal end of the gut. The 
peritonaeum was normal, but a very large retro-peritonael abscess, communicating with 
the rectal pouch above the cancer, extended high up along the front of the sacrum, and 
contained a large quantity of extremely fetid pus. 

Case II. — John Barnett, clerk, aged fifty. Inoperable cancer of lower end of 
rectum. November 15, 1886. — Inguinal colotomy with formation of spur at Mount Sinai 
Hospital. November 22d. — Stitches that were not absorbed, removed. Funnel-shaped 
artificial anus, no prolapse of gut. August 10, 1887. — Wears, with comfort, a small 
hollow rubber ball over the fistula. 

Case III. — Stephen Y., government official, aged sixty-one. Far-gone rectal cancer, 
with involvement of _the prostate and old strictures of the pendulous part of the 
urethra. November 15, 1886. — Inguinal colotomy with formation of spur at Mount 
Sinai Hospital under ether. November 16th. — Lobular pneumonia, probably caused by 
aspiration of mucus during the anaesthesia. By November 25th, the acute febrile 
symptoms had subsided, but profuse purulent sputa were continually expectorated. 
The bladder also caused much trouble, although the tight strictures had been well 
dilated. The urine contained much pus, later on blood, coming from the ulcerated 
portion of the cancer occupying the neck of the bladder. The colotomy wound healed 
kindly, and a satisfactory artificial anus had been secured. The chronic bronchial 
catarrh, fetid cystitis, and later pyelo-nephritis, however, hastened the death of the 
patient, which occurred on December 23d. 



XII. HYDROCELE, VARICOCELE, AND CASTRATION. 

1. Hydrops of the tunica vaginalis of the testis is either an essential 
disorder per se, or is symptomatic of some acute or chronic affection of the 
testicle. If it be produced by acute epididymitis and orchitis, it is transient ; 
21 



150 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



but if its cause is tuberculosis, or cancer, or syphilis of the testicle, it- 
assumes the character of a chronic complaint. For the sake of a correct 
prognosis the recognition of secondary hydrocele is important, as it is im- 
probable that, brought on by these affections of the testicle, hydrocele can 
be cured by either tapping and injection or the radical operation. 

If the hydrocele is very tense, preliminary tapping is advisable, in order 
to afford an opportunity for estimating the condition of the testicle. 
Should this be found rugged, swollen, and hard, it is very doubtful that 
measures directed to the cure of the effusion will be successful, unless the 
condition of the testicle be improved by appropriate treatment. Gummy 
swellings will usually disappear under antisyphilitic medication, and with 
them the hydrocele. Tuberculosis and cancer, on the other hand, will 
require castration. 

The cure of simple hydrocele by tapping and subsequent injection with 
tincture of iodine or pure carbolic acid is safe, and is generally followed by 
cure. The only caution to be taken is a proper disinfection of the trocar or 
cannula to be used, by either boiling in carbolized lotion (five per cent), or 
by heating the instrument in an alcohol-flame. Care must also be exercised 
not to leave behind in the sac too large a quantity of the tincture of iodine, 
as there is on record a case of acute iodine-poisoning brought on by that 
circumstance. 

Volkmanrt s radical operation is also safe, and offers the best chances 
of a permanent cure ; but it necessitates longer confinenent of the patient 
than the preceding method. The author has performed this operation suc- 
cessfully thirty-two times on thirty-one patients, and no serious disturbance 
was observed during the course of healing. In each case 
cure was complete in from two to three weeks, and was 
permanent. Lately the operation was done with the aid 
of local anaesthesia by cocaine. 

The procedure is as follows : The penis and scrotum 
are shaved, scrubbed off, and disinfected. A rubber band 
or drainage-tube is tied about the root of the penis and 
scrotum, and about twenty minims of a five-per-cent 
solution of cocaine are injected along the prospective 
line of incision. The skin and dartos are incised for 
about two inches, and the exposed tunica is opened. A 
grooved director is slipped into the sac, which is then 
slit open, this incision being somewhat shorter than the 
cutaneous one. The sac is mopped out with a sponge 
dipped in a five-per-cent solution of carbolic acid. After this the tunica is 
stitched to the skin by a continuous suture of fine catgut. A small drain- 
age-tube is inserted and secured from slipping in by transfixion with a 
safety-pin. The constricting rubber band is removed, and the scrotum is 
held compressed between two sponges for a few minutes to stanch any pos- 
sible haemorrhage. A small strip of disinfected rubber tissue is laid on the 
wound, which is enveloped, together with the entire scrotum, in a dry dress- 




Fig. 121.— Diagram 
illustrating volk- 
niann's operation 
for hydrocele. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 151 

ing, held down by a rubber bandage applied in the manner described in the 
paragraph on herniotomy. (Fig. 121.) 

The dressings are changed on the tenth day after the operation. On 
the second day the movement of the bowels is attended to by enema or laxa- 
tive. On changing the dressings the patient can be permitted to get up and 
to exercise moderately. The wound is dressed with a strip of iodoformed 
gauze until it is healed. 

2. Varicocele of a moderate degree is best treated according to Keyes's 
plan, which consists of subcutaneous ligature of the distended veins with 
catgut. The scrotum being cocainized, the cord is separated from the vari- 
cose veins, and is held in the grasp of the thumb and index of the left hand, 
the patient standing during the procedure. A straight Peaslee's needle, 
armed with a loop of silk, is thrust through the scrotum from in front until 
its eye appears behind the scrotum. The left hand releasing its grasp, it is 
used for placing the ends of a medium-sized thread of catgut into the loop 
of silk, which is then pulled through forward and out of the anterior punct- 
ure-hole, and the catgut is released from the silken loop. Now the left 
hand grasps again the scrotum, and the needle is reinserted exactly into the 
anterior puncture-hole, and carried around the varices externally to them, 
and close to the scrotal integument backward, until it emerges exactly from 
the posterior puncture. The other end of the catgut thread is then taken 
up by the loo}3 of silk, and is brought out through the anterior aperture by 
withdrawing the needle. Both ends of the ligature are now seen emerging 
from the anterior puncture-hole. They are tightly knotted, cut oh* short, 
and disappear in the scrotum as soon as released. A slight amount of hard 
swelling will appear around the place of ligature the next day, but will not 
cause sufficient discomfort to prevent the patient from attending to his avo- 
cation. 

The author has employed this method with the best success in four 
cases. 

Extensive varicocele can be cured only by free exposure, double ligature, 
and excision of the dilated veins. Under aseptic precautions this measure 
is free from danger. 

Case. — Erail Luhning, baker, aged twenty-one. Large varicocele of the left side, 
extending down to the middle of the inner aspect of the thigh. April 25, 1882. — At 
the German Hospital the scrotal varices were exposed by incision, and a large plexus 
was separated and tied above and below. The intervening veins were exsected. 
Another incision of eight inches in length exposed the varicose veins extending down 
the thigh, and they were also exsected after being secured by double ligature. A 
rather wide strip of attenuated skin had to be removed along with the veins, prevent- 
ing entire closure of the femoral wound by suture. Uninterrupted cure of the scrotal 
wound by primary union of the femoral one by granulation. June 22d. — Patient was 
discharged cured. 

Four more somewhat less extensive cases were treated in a similar man- 
ner, and all healed by the first intention. 

Care must be taken not to remove all the veins of the pampiniform 



152 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

plexus. In the author's sixth case necrosis of the testicle was caused by too 
extensive excision of the dilated veins. 

Case. — Joseph Stern, baker, aged twenty-two. Extensive varicocele of the left 
side. March 17, 1886. — Excision of varices at the German Hospital. March 27th. — 
Necrosis of testicle was noted. A few of the stitches had given way, and the yellow- 
ish, discolored testis was distinctly visible. April 8th. — The testicle came away with 
very moderate sero-purulent secretion. April 26th. — Patient was discharged cured. 

3. Castration is indicated by neoplasms, tuberculosis, or syphilis of the 
testicle, in the latter case, however, only when the disease is not amenable 
to systemic treatment, and is a source of much suffering. 

The author' 's procedure for castration is as follows : The patient's geni- 
tal region is shaved, scrubbed with soap and hot water, and disinfected with 
corrosive-sublimate lotion, or, if any open ulcer or fistula be present, these 
are finally syringed or touched up with an eight-per-cent solution of chloride 
of zinc. First, the seminal cord is exposed well above the diseased testicle, 
and, being separated, is taken up by the index of the left hand. The ves- 
sels composing it are successively grasped by separate artery-forceps, while 
the vas deferens remains intact. As soon as all the vessels are thus secured, 
they are nipped off one after the other with the scissors in front of the 
artery-forceps, and are at once tied. The vas deferens is cut through. 
Before being released, the mesial end of the severed cord is somewhat relaxed 
and carefully inspected, to see whether all bleeding be stanched or not. 

By making the division of the cord the first step of the operation, the 
subsequent parts of the procedure are made decidedly less bloody. Dissec- 
tion of the testicle proper is much easier and more rapid than if the reverse 
order is observed, and the stump of the cord serving as a convenient handle, 
contact of the surgeon's fingers with ulcerating surfaces or fistulas can 
altogether be avoided. A few more ligatures will be generally needed along 
the bottom of the scrotum. 

A drainage-tube is inserted, extending from the inguinal ring down to 
the lower angle of the cutaneous incision, and then the wound is united by 
interrupted catgut sutures, the edges of the cut being held pinched up by 
the fingers in passing the stitches. A dressing similar to that used after 
herniotomy is applied and left on generally for eight or ten days. The tube 
is removed with the first dressing. 

Tying of the cord in mass saves a little time in operating, but the stump 
generally necroses, and cure is very much delayed by the slow process of its 
detachment. 

Castration was performed by the author twenty times ; in fifteen cases 
for tuberculosis. One of these cases died of croupous pneumonia, probably 
induced by ether anaesthesia. 

Case. — Moses H., merchant, aged sixty. January 24, 1887. — Castration for tuber- 
culosis of right testicle at Mount Sinai Hospital under ether. The operation did not pre- 
sent anything unusual, and the patient did well after it until two o'clock on the after- 
noon of January 26th, when suddenly high fever with dyspnoea appeared, and developed 
into coma within a few hours. At 6 p. m. the thermometer indicated 106-7° Fahr. in 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 153 

the rectum ; at 9'55 p. m. the patient died. Dullness at the base of the right lung, 
made out a few hours before death, corresponded to an area of fresh lobar pneumonia 
found at the autopsy. The wound, peritoneal cavity, and kidneys were normal. 

Fourteen cases castrated for tuberculosis all recovered. 

In one case castration was done for syphilitic gumma of the left testicle 
of five years' standing, which had remained uninfluenced by various kinds 
of constitutional treatment. 

Case. — John W. G., brewer, aged thirty-eight. Large hydrocele caused by chroDic 
specific disease of the testicle. March 4i 1887. — The hydrocele was incised, and the 
testicle was found very much enlarged ; the rugged and hard epididymis was occupied 
by a solid fibrous mass extending well into the glandular tissue of the testicle. Cas- 
tration was at once done. March 15th. — Patient discharged nearly cured, the place of 
exit for the drainage-tube presenting a small spot of granulations. 

In two cases ablation of the testicle had to be done for malignant neo- 
plasm. They recovered. 

Case I. — Jacob Praeger, tailor, aged seventy-two. Very large giant-cell sarcoma 
of right testis. December 4, 1879. — Castration. Preparation of the bowels by laxatives 
was insufficient, and on the third day after the operation violent colic developed, which 
could not be controlled by opiates. In the night a large stool escaped into the bed, 
the dressings and the wound were soiled, and in a few hours fever set in. The wound 
was injected with an eight-per-cent solution of chloride of zinc, which checked the 
fever. Much sloughing tissue came away, but patient recovered, and was discharged 
cured about five weeks after the operation. 

The author's experience in this case taught him the valuable lesson of 
never trusting the patients' statement regarding the action of their boivels, 
and never leaving the manner of preparation of the intestine to their judg- 
ment. In this case the patient assured the author that citrate of magnesia 
acted on him like a charm. Citrate of magnesia was taken, with the result 
reported above. Had a good dose of oil or calomel raked out the flaccid 
and coprostatic gut of the old man before the operation, his life would not 
have been endangered by subsequent fecal infection of the wound. 

Case II. — Siegmund Hertz, clerk, aged thirty-two. August 24, 1885. — Castration 
of right testicle for myxosarcoma at Mount Sinai Hospital. Primary union. Septem- 
ber 15th. — Patient discharged cured. 

Twice castration ivas done for spontaneous gangrene of the testicle. 
Both cases recovered. The record of one was lost ; that of the other is as 
follows : 

Case. — George Otto, butcher, aged thirty-nine, admitted, February 2, 1880, to 
German Hospital with an enormous emphysematous swelling of the left testicle. The 
organ had nearly the size of a man's head, was dusky red and hot, showed crepitus, 
and gave tympanitic percussion-sound. The patient, a powerfully built man, showed 
symptoms of most acute septic intoxication. He stated, on being shaken out of his 
stupor, that the swelling had come on three days ago suddenly with much pain after 
a probatory puncture. Immediate ablation of the organ was done. The skin was pre- 
served, and the very large wound cavity was filled with a packing of carbolized gauze. 
An almost immediate improvement of the patient's general condition followed. The 



154 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



wound healed rather rapidly by granulation. February 26th. — Patient was discharged 
cured. Examination of the specimen showed bloody infarction of the testis and epi- 
didymis, with far-gone disintegration and softening of the tissues. The tunica and 
subcutaneous connective tissue were in a state of emphysematous gangrene. 



XIII. ASEPTIC OPERATIONS ON THE RECTUM. 

1. General Observations. — The aseptic performance of rectal operations 
done for hsemorrhoidal or other tnmors requires a careful preparation of 
the gut. It consists, first, of the 
administration of a cathartic like 
castor-oil or calomel several 
in elderly subjects a 
week before the op- 
eration, followed up 
by the daily exhibi- 
tion of a saline laxa- 
tive, to be given on an 
empty stomach. Four 
hours before the time of the 
operation a large enema of 
soap-water is administered, 
and, as soon as it has acted, 
a full dose of opium is given by mouth 
in the shape of a suppository. 

When the anaesthetized patient 




Fig. \ 22. — Lateral view of patient in Bozeman's position. 



or 



is introduced into the rectum 



is laid on the operating-table, a good- 
sized sponge attached to a stout silken thread is 
thrust well up the rectum, and, the sphincter 
being thoroughly stretched by manual force, the 
anus and rectal pouch are flushed with a stream 
of corrosive-sublimate lotion (1 : 1,000) thrown 
from an irrigator. 

During the progress of the operation irrigation 
has to be kept up con- 
stantly at short inter- 
vals. When the perito- 
naeum is approached, 
or has to be invaded by 
the surgeon, Thiersch's 
solution is substituted 
for the mercuric lotion 
as an irrigating fluid. 
2. Hemorrhoids.— 
A varicose condition 
of the haemorrhoidal 
veins of recent origin, 
caused by some dis- 




Fig. 123. — Posterior view of patient in Bozeman's position. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 155 

turbance of the portal circulation, is often amenable to general treatment 
by fulfilling the causal indication. Eemoving a fecal retention, or regu- 
lating the portal circulation with a dose of calomel, followed up by a course 
of Carlsbad salts, will often do away with the haemorrhoids caused by these 
conditions. Or regulation of the heart's action by digitalis in valvular 
lesions will be followed by marked improvement. When the haemorrhoidal 
nodes are in a state of acute phlebitis, marked by painful hot swelling and 
fever, topical applications of cold in the shape of enemata of ice-water or 
iced compresses will give much relief. 

Aggravated cases, however, especially when there is a state of prolapse 
of the mucous membrane of the anus, can be cured only by operative meas- 
ures. 

Of all operations for the cure of haemorrhoids, that by ligature com- 
mends itself as the simplest and safest. This statement is based on an 
experience gathered from several hundred cases operated by the author 
according to various methods. 

The manner of procedure is as follows : The anaesthetized patient is 
brought either in the lithotomy position, with a hard cushion under his 
buttocks, or he is arranged in Bozeman's manner for the operation of vesico- 
vaginal fistula (Figs. 122 and 123). This latter position is especially use- 
ful where the assistance needed for holding the patient in the lithotomy 
position can not be procured. In both cases the feet and legs of the patient 
should be protected from exposure by a wrapping of rubber sheets. These 
should be covered over with clean towels wrung out of mercuric lotion for 
the protection of the assistants' hands from contamination. 

Selecting the lithotomy position, the patient's palms should be brought 
in contact with his soles, and this relation should be secured by tight band- 
aging. The operator, well protected by a rubber apron, takes a seat in front 
of the patient, and proceeds to vigorously stretch the sphincter ani muscle 
with his thumbs inserted in the anus. As soon as the sphincter is paralyzed 
by stretching, the haemorrhoidal nodes, external and internal, will spontane- 
ously protrude. A sponge secured with a thread of silk is thrust into the 
rectum, and the field of operation is cleansed by irrigation. The lowest 
node is grasped with an artery forceps, and, being well drawn out, is cir- 
cumscribed by a shallow incision made with a pair of curved scissors. A 
curved needle is taken, armed with a double thread of stout disinfected silk, 
and with it the base of the tumor is transfixed from without inward. The 
silk is cut near the needle, and, the threads being separated, the base of the 
node is tied in two portions. The node is cut off below the ligatures, and 
then the remaining nodes are attended to in a similar manner. When the 
operation is finished, some iodoform powder is rubbed into the nodal stumps, 
and, after a final irrigation, the sponge is withdrawn from the rectum, 
which is mopped out dry with another sponge attached to a long stick or 
sponge-holder. (Fig. 124, a and c.) 

A hollow tampon is next prepared by wrapping a few layers of iodoform- 
ized gauze around a piece of stout rubber tubing three inches long. This 



156 



KULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



isjntroduced into the rectum well beyond the sphincter, and its protruding 
end is transfixed with a large-sized safety-pin. (Fig. 125.) 

The object of this tampon is twofold. Its main object is to facilitate 

the escape of flatus, a circumstance highly 
appreciated by elderly flatulent individuals. 
Another purpose is the prevention of oozing 
from the stitch-holes. 

The anal region is thickly anointed with 
vaseline, and, the 
safety-pin being un- 
der-padded with a 
few strips of iodo- 
formized gauze, a 
large pad of corros- 
ive-sublimate gauze 
is held down to the 
anus by a T-band- 
age. (Fig. 126.) 

Forty-eight hours 
after the operation 
four ounces of sweet 
oil are injected into 
the rectum through 
the rubber tube, which 
can be withdrawn a 
short while after with 
very little pain to the 
patient. A large ene- 
ma of soap-water is at 
once administered, and 
generally is followed by an evacuation of the 
bowels. After the stool another small enema 
is given to cleanse the haemorrhoidal stumps 
of adherent faeces. The anus is dressed with 
a strip of iodoform i zed gauze and a pad as 
before. 

The next morning a dose of salts is given, and, stool following, the rec- 
tum is again washed out afterward. This practice may have to be repeated 
once or twice within the next few days. 

The patient may be permitted to get up about ten days after the 
operation, but must remain at home till after the detachment of the 
ligatures. 

Cauterization with fuming nitric acid was formerly also much employed 
by the author ; but in one case almost fatal haemorrhage occurred from a 
small artery just within the sphincter on the detachment of the eschar. 
Since then the author has abandoned this practice. 




SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



157 




Fig. 125.— Tampon-tube. 



Case. — Mr. M. P., gilder, aged thirty-one. Febru- 
ary ££, 1882.— Cauterization of external and internal 
haemorrhoids with nitric acid. March 10th. — At 2 a. m. 
the author was hastily summoned to the bed-side of 
the patient, and found him in a collapsed condition. 
He reported that shortly after supper he felt a desire 
to stool, and had a copious evacuation. Evacuations 
followed since then about every hour, but, the closet 
being dark, he could not say whether the stools were 
bloody. At 1 a. m., on coming back to bed from the 
water-closet, the patient fainted. Being brought to 
bed, another stool followed, consisting of a large clot 
and some liquid blood. The patient was at once anaes- 
thetized, and, a speculum being inserted, a rather large- 
sized artery was seen spurting from where an eschar 
had been detached just inside of the sphincter. The 
vessel was seized and tied, and the patient made a good 
recovery. 

LangenbecFs clamp and actual cautery meth- 
od is very good and safe, its only drawback be- 
ing the necessity for a cautery apparatus. Care 
must be taken not to grasp with the clamp the 
nodes too near their base, as the resulting eschar is apt to be very large, 
and anal stricture may follow. The hollow tampon is very useful in this 

method also, and its 
use can be warmly 
recommended (Fig. 
124, b). 

3. Rectal Tu- 
mors. — Since the 
publication of Volk- 
mann's remarkable 
results achieved by 
extirpation of the 
rectum for cancer, 
the operation, for- 
merly condemned, 
has met with fre- 
quent imitation. 
The author's mel- 
ancholy record of 
six deaths out of 
eight operations has 
nothing to inspire great confidence. It must be said, however, that most 
of these operations were performed under very unfavorable conditions. All 
the patients presented instances of very extensive involvement of the gut, 
requiring in each case the removal of more than three inches — in one case, 




Fig. 126. — T-bandage in situ. 



158 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

nine inches — of intestine. Almost all of them were performed during the 
first years of the author's independent surgical activity, when his mastery 
of the difficult technique, both of the aseptics and hemostasis of the region 
in question, was imperfect. Much unnecessary haemorrhage was incurred, 
and several of the most important cautelae against infection remained unem- 
ployed. Accordingly, two patients died shortly after the operation of col- 
lapse, due to acute anaemia ; two died of purulent peritonitis, caused by 
infection of the incised peritonaeum ; one died of septicaemia, induced by 
the presence of a large retroperitoneal abscess, extending far up in front of 
the vertebral column. One patient, a very fat, flabby woman, died of lobar 
pneumonia at a time when the wound was nearly healed. 

Two cases of very extensive removal of the rectum made a remarkably 
short and easy recovery. 

Case I. — Ed. Turner, mechanic, aged twenty-nine. Extensive soft adenoid cancer 
of the rectum, of rapid growth. The involved part of the gut was freely movable, 
although its upper limit could not be reached by the tip of the index-finger. Novem- 
ber i#, I884. — Extirpation of the rectum at Mount Sinai Hospital. As the growth 
did not extend downward to within an inch of the sphincter, this muscle was pre- 
served. The coccyx was exposed by a posterior median incision, and was exsected. 
The mucous membrane of the lower end of the gut was dissected up in the shape of a 
cylinder, and was closed by a ligature to prevent the escape of rectal contents during 
the operation. Every vessel was immediately secured and tied, either at being cut or 
before division, if it could be previously recognized. The levator ani muscle was 
detached by dissection from the intestine. All resisting bands of* tissue, mostly con- 
taining vessels, were secured by double mass ligatures before being divided. Most diffi- 
culty was met with in freeing the gut from its attachments to the deep pelvic fascia, 
but by dint of mass ligatures this was also overcome. As soon as the pelvic fascia was 
passed, the intestine readily yielded to traction, and was withdrawn until the upper 
limit of the tumor was distinctly felt through the walls of the gut. The peritonaeum 
was detached anteriorly by blunt separation, but it had to be incised on the posterior 
aspect of the rectum to permit complete removal of the growth. The gut was grasped 
with a large clamp-forceps about an inch above the tumor, and was severed. The 
patent orifice of the rectum was carefully cleansed and disinfected, and, the clamp 
being removed, a number of vessels of the rectal wall were secured and tied. During 
the whole operation the wound was almost constantly irrigated with corrosive-subli- 
mate lotion (1 : 2,500). The peritoneal incision being closed by catgut suture, the 
wound was loosely packed with iodoformized gauze after the insertion of two drain- 
age-tubes into its bottom, and the gut was attached to the skin by two silk sutures. 
The ends of the drainage-tubes were left projecting from the dressings, and the wound 
was flushed through them at regular intervals of an hour. The temperature remained 
normal except on the sixth day, when it rose to 103° Fahr. The patient complained 
of colicky pains, and a saline purge was administered. A stool following, the fever 
disappeared. The wound was carefully cleansed by irrigation after each stool, and 
healed in spite of its great extent in six weeks. The removed portion of the gut meas- 
ured, when laid upon the table, just five inches. 

The resulting incontinence of the widely patent gut was remedied by a procto- 
plasty performed February 28, 1885, at the German Hospital. The divided ends of 
the preserved sphincter muscle were dissected out, and were united by a row of catgut 
stitches placed in the median line. In April, 1887, the patient was free from relapse. 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 159 

Case II. — Eugene HafTner, waiter, aged twenty-four. Relapsing cancer of rectum 
after extirpation done by Dr. F. Lange. February ££, 1887. — Extirpation of addi- 
tional two inches of the gut at the German Hospital. Peritonaeum was found descended 
to within half an inch from the skin. It had to be freely incised, and was subsequently 
closed by five catgut sutures. Uninterrupted recovery. April 2d. — Patient was dis- 
charged cured. 

The main source of infection is the interior of the gut. To exclude this 
danger, the lower end of the rectum must be closed by a circular ligature. 
When the gut is divided above, care must be taken to prevent soiling of 
the wound by escaping intestinal contents. 

XIV. ASEPTICS OF THE BLADDER. 

1. Catheterism, — Infectious processes rarely originate in the bladder 
itself. Their most common way of entrance is by the urethra from with- 
out ; next to this come the modes of infection from within — that is, by 
descent from the kidneys or by extension of contiguous septic processes 
from the organs located in the vicinity of the bladder, as for instance from 
peritoneal or retro-peritoneal suppurations. 

As before indicated, the most common source of infection of the bladder 
is an unclean catheter. The ordinary methods of cleansing metallic catheters 
by flushing with hot or cold water, and subsequent rubbing off with a clean 
towel, are altogether inadequate. In order to secure their absolute cleanli- 
ness, the same processes of sterilization must be employed that were recom- 
mended for cleansing other hollow tubes — notably, aspirating needles and 
trocars. Boiling for an hour in water, or passing the instrument through 
an alcohol flame until all organic matter contained in its lumen is volatilized 
by burning, is meant thereby. Only after smoke and steam have ceased to 
escape from the catheter can it be declared to be surgically clean. 

Before use, the cleansed catheter should be placed in a tray or flat pan 
filled with tepid salt water (6 : 1,000, or one heaped teaspoonful to a quart 
of boiled water) ; the surgeon's hands should be previously well washed with 
soap and hot water, and the instrument should be anointed with iodoform- 
ized vaseline of the strength of 1 : 50 (fifteen grains to two ounces). 

Note. — The ordinary solutions of corrosive sublimate or carbolic acid corrode the mucous 
membrane of the urethra and bladder, often causing intense pain and reflex symptoms. The 
resulting denudations of the epithelial layer all may serve as portals of subsequent infection, 
manifesting itself in the form of urethral fever, urethritis, cystitis, and, in extreme cases, 
metastatic processes. None of these very active germicides should be introduced into the 
healthy urethra or bladder : first, because they are unnecessary ; and, secondly, because they 
may do harm. Simple immersion of a filthy catheter into these germicidal lotions will not dis. 
infect it sufficiently, and, if some of the strong solution be carried into the urinary passages 
along with a filthy catheter, the chances of infection will only be increased by the combination. 
Catheters that were immersed in strong disinfectant solutions should be freed from them before 
being used. 

In passing the instrument into the bladder for exploration or evacuation, 
the utmost gentleness should be exercised, not only for the sake of the 



160 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

patient's comfort, but also because it is of importance not to injure the 
urethral mucous membraue. Certain parts of the normal male urethra will 
often raise obstacles to the passage of the instruments which should never 
be overcome by force, but only by patient and gentle manipulation. 

The first obstacle is usually met at the suspensory or triangular ligament. 
Holding the shank of the catheter parallel with the abdominal wall while 
gently extending the penis upward in the same direction, thus pulling the 
latter over the former like a glove-finger over a finger, will easily guide the 
beak of the catheter around the promontory formed by the inferior margin 
of the symphysis pubis. 

The second obstacle will be occasionally found in the sinus of the 
bulbous portion. This pitfall must be avoided by exerting digital pressure 
upon the peringeum, and indirectly upon the beak of the catheter while 
gently depressing its handle. In sensitive urethrse, the compressor urethrae, 
or • "' cut-off " muscle, will offer by reflex contraction considerable resist- 
ance to the progress of the operation, especially if an instrument of small 
caliber be employed. It is injudicious to force this obstacle. A better 
plan is to abide the moment when the muscle will relax, the instrument 
being held against the resisting band by gentle pressure. As soon as relaxa- 
tion begins, the point of the catheter will be felt slipping through the 
contracted part of the urethra. 

The enlarged prostate is the last and most difficult, because deepest, 
impediment that may retard the operator. A long-beaked instrument will 
penetrate to the bladder easier than any other one. The handle of the 
catheter must be deeply depressed between the thighs of the patient, and, if 
this be insufficient, the tip of the left index introduced in the rectum must 
aid the entrance of the beak by gentle upward pressure. 

Properly performed catheterism of a healthy urethra and bladder should 
not be followed by haemorrhage. 

Soft catheters made of gum elastic or webbing impregnated with 
resinous matter are never safe unless their history is known to the operator. 
They should be new, or, at least, such should never be employed that had 
been previously used on a septic case, or were not carefully cleansed, disin- 
fected, and preserved in a proper manner after use. 

Soft gum-elastic or Nelaton catheters are very cheap, and need not be 
preserved after having been used in a septic case. Before employing a soft 
catheter, it must be soaked for ten minutes in hot soap-water and flushed 
out with it ; then it is disinfected with a strong germicide lotion, preferably 
corrosive sublimate, from which it must be freed again by another flushing 
with salt water before it is anointed with iodoformized vaseline for intro- 
duction. 

After use, the catheter should be again flushed out thoroughly with car- 
bolic or mercurial lotion, dried, and put away in a tight box or wide- 
mouthed bottle. If needed frequently, the catheter should be kept im- 
mersed in a five-per-cent carbolic lotion. Before use, however, the adherent 
carbolic lotion must be always removed by washing in salt water. The 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 161 

author saw a considerable number of cases in which catheterism had to be 
done for some time after rectal operations, and in which troublesome 
urethritis developed on account of the corrosion caused by frequent contact 
of the urethral mucous membrane with the carbolic acid adherent to the 
elastic catheter. 

Searching a non-dilated bladder for stone, tumors, or foreign bodies 
would lead to superficial injury of the mucous membrane ; therefore, dilata- 
tion, by injecting three or four ounces of salt water, should precede every 
exploration. After completion of the search, clots should be removed by 
irrigation with the saline solution. 

These remarks refer to bladders only that discharge normal urine. 

Whenever examination of the urine gives evidence of a catarrhal or 
septic condition, every intravesical manipulation must be preceded by disin- 
fection of the bladder by Thiersch's solution, or a lotion consisting of one 
part of permanganate of potash to five thousand parts of tepid water. The 
operation should be completed by another disinfecting irrigation of the 
organ. 

2. Litholapaxy. — The rapid and complete evacuation of the bladder in 
one session, of all fragments produced by crushing concrements with a 
lithotrite, forms a most valuable improvement of the technique of lithotripsy. 
Bigelow's evacuator enables the surgeon to free the bladder at once of all 
sharp-edged fragments of stone. This circumstance justifies the prolonga- 
tion of the operation to an extent formerly considered unsafe, as subse- 
quent irritation caused by the presence of sharp fragments is thus done 
away with. 

Before introducing the lithotrite, strictures ought to be cut or divulsed, 
and the bladder ought to be thoroughly washed out with tepid permanganate- 
of-potash or boro-salicylic solution. After this the bladder is filled with 
from three to four ounces of tepid boro-salicylic lotion, and the lithotrite is 
introduced well anointed with iodoformized vaseline. The penis is tightly 
deligated with a piece of rubber tubing, and the stone, being grasped, is 
crushed first into a number of larger, and subsequently into as many small 
fragments as possible. The crushing instrument is removed and is replaced 
by the evacuating catheter, which is connected with the evacuating bulb, 
that was previously filled with boro-salicylic lotion. All small fragments 
are next sucked out of the bladder by the apparatus. Should a peculiar 
click indicate the fact that one or more fragments, too large to pass the 
catheter, are still remaining, the lithotrite must be introduced anew to com- 
plete their reduction to a proper size, after which complete evacuation will 
meet no difficulty. 

The bladder is washed out again until the irrigating fluid returns free 
from blood, and the patient is brought to bed. 

Small stones, especially of the softer varieties, are eminently suited for 
this treatment, which has the great advantage of a short convalescence ; 
but its disadvantage of a possible relapse from failure to remove all frag- 
ments can not be denied. 



162 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Case I. — Moritz Witzkal, peddler, aged fifty. April 5, I884. — Litholapaxy at the 
German Hospital. Uratic stone with phosphatic shell weighing four drachms fifty- 
five grains. Duration of operation, thirty-five minutes. Discharged April 28th. In 
June, patient was readmitted for stone, which was removed by Dr. Adler by median 
lithotomy. 

Case II. — Mr. E. B., clerk, aged twenty-one, renal colic followed by symptoms of 
stone in the bladder, which was diagnosticated by sounding. In March, 1887, lithot- 
rity and evacuation. The bladder symptoms continued until June, when Dr. Schede, 
of Hamburg, removed another small calculus. 

The author performed litholapaxy in four more cases. 

Case III. — Edward Mink, baker, aged twenty-one. January 26, 1881. — Rapid 
lithotrity for a phosphatic calculus weighing two hundred and fifty grains. March 
5th. — Patient discharged cured. 

Case IV. — Henry Bowitz, agent, aged forty. April 24, I884. — Litholapaxy for 
uratic calculus, weighing three drachms and ten grains, at Mount Sinai Hospital. 
May 10th. — Patient discharged cured. 

Case V. — Francis Johnson, druggist, aged forty-seven. Phosphatic calculus, 
ammoniacal urine. October 6, 1883. — Rapid lithotrity at Mount Sinai Hospital. 
Weight of stone, forty-seven grains. Duration, fifty-five minutes. Discharged cured, 
October 27th. 

Case VI. — Philip Prinz. shoemaker, aged fifty-nine. Rapid lithotrity for small 
uratic calculus, done January 25, 1887, at German Hospital. On the day following 
the operation all the symptoms of stone disappeared, but the patient sustained a burn 
of the legs requiring surgical treatment. This delayed his discharge until March 17th. 

Intense forms of cystitis caused by the presence of calculi require after 
lithotrity continued treatment of the bladder by irrigation. 

3. Cystotomy. — In perineal as well as in suprapubic cystotomy, the con- 
dition of the urine should serve as a guide in determining whether aseptic 
or antiseptic measures have to be observed during the operation. When the 
normal condition of the urine indicates that the vesical mucous membrane 
is in a healthy state, strong disinfecting solutions should not be used within 
the bladder, and the surgeon's chief attention should be directed to the care- 
ful cleansing of his instruments, in order to avoid the introduction of filth 
into the bladder. For purposes of filling and cleansing, a saline or 
Thiersch's solution will be all sufficient. 

In cases characterized by pyuria, with or without ammoniacal odor, or 
with outright fetidity of the urine, disinfection of the bladder must precede 
and follow each operation. 

The rules of asepticism referring to the treatment of the external wound 
must also be scrupulously observed. During the after-treatment, drainage 
of the bladder may be required, especially in cases where a septic condition 
of the organ would render retention of fetid urine undesirable or risky. A 
rather stout rubber drainage-tube inserted in the bladder will answer every 
practical purpose. 

(a) Perineal Section : 

Case I. — Fred. Kurtz, aged fifty-five. Phosphatic stone, ammoniacal urine. Feb- 
ruary 1, 1881. — Lateral lithotomy at the German Hospital. Weight of stone, three 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 



163 



drachms and forty grains. No reaction or fever. Continued washings of bladder with 
salicylic-acid solutions. April 10th. — Discharged cured. 

Case II. — Hugo Liedtke, aged three and a half. Small uratic stone. March 19, 
1881. — Lateral lithotomy with the assistance of the family attendant, Dr. Hassloch. 
Weight of stone, eighteen grains. April 15th. — Discharged cured. 




Pig. 127.— Arrangement of patient for perineal cystotomy. Feet wrapped up in disinfected towels. 

(b) Supeapubic Section. — Tumors, a very large prostate, encysted or 
very large stones, oxalic concrements, or rebellious cystic haemorrhage from 
dilated veins of the neck of the bladder, indicate the selection of the high 
operation. Petersen and Garson's proposition to distend both bladder and 
rectum before cutting, marks a most valuable improvement of the method, 
as injury to the anterior reflection of the peritonaeum can be thus avoided. 
A soft rubber bag, or "colpeurynter," similar to Barnes's dilator, is intro- 
duced into the rectum, and is filled with from fifteen to eighteen ounces of 
water. Escape of the water is prevented by attaching an artery forceps to 
the end of the tube. 

Seven or eight ounces of tepid salt water or boro-salicylic lotion are 
injected into the bladder, and the penis is tied with a piece of rubber tub- 
ing. The patient's shaved suprapubic region is carefully disinfected, and 
a median incision is made, commencing about three inches above, and ex- 
tending to the symphysis. The recti muscles are separated, and the pre- 
vesical fat is incised. Care must be taken not to injure the reflexion of the 
peritonceum, which may be looked for in the upper angle of the ivound. In 
many cases the peritonaeum will not come in view at all. Should distention 
of the rectum and bladder not suffice to push up and out of the way the 
peritoneal fold, this must be separated from the bladder by blunt dissection, 
to be done preferably by the tips of the fingers. Vessels crossing the pre- 
vesical space should be divided between double ligatures. 

The bladder is transfixed on each side of the median line with curved 
needles, carrying fillets of silk. The vesical incision is made between these 



164 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



hold-fasts with a sharp-pointed bistoury. In cases of doubt, the presenting 
organ may be first punctured with a hypodermic needle. While the silken 
threads keep the vesical wound patulous, the surgeon's finger explores the 
interior of the bladder. Stones are then extracted with forceps, or the 
scoop, or even with the fingers, tumors are inspected and excised under the 
guidance of the eye, and bleeding varices of the neck of the bladder are 
grasped and tied off or touched with the thermo-cautery. 

After thorough irrigation, a T-shaped drainage-tube (Fig. 128) is inserted 
in the bladder, and the external wound is loosely packed with iodoformized 
gauze. A split compress of the same material is ar- 
ranged about the projecting end of the tube, and is 
covered with a number of compresses consisting of 
corrosive-sublimate gauze. The skin all around the 
wound is profusely anointed with iodoformized vase- 
line, and the dressings are held down by a few turns 
of a roller-bandage. The patient is brought to bed, 
and is laid on his side upon a circular air-cushion, 
his back being supported by a number of cushions 
held up by the backs of several chairs, or by boards 
stuck into the side of the bed. As the lateral posi- 
tion has to be maintained for three days at least, 
sides should be changed every two or three hours. 
The drainage-tube projecting from the dressings is 
connected with a longer tube, that is led into a urinal 
placed alongside the patient in or out of bed. As 
soon as the urine ceases to be bloody, and its reaction 
becomes acid, the patient may be allowed to assume 
the supine posture. The drainage-tube can be re- 
moved on the fifth day, when the wound will be usu- 
ally found in a state of healthy granulation. The packing of iodoformized 
gauze has to be continued as long as urine escapes through the wound. As 
soon as urination per vias naturales is re-established, the wound should be 
dressed as any other superficial wound. 

Case I. — Martin Gyr, laborer, aged fifty. Large oxalic calculi of ten years 1 stand- 
ing, with undilatable bladder. Wretched general condition. April 12, 1886.— Supra- 
pubic lithotomy at the German Hospital under chloroform, which was preferred to 
ether on account of the presence of casts in the urine. Two immovable stones were 
found occupying the contracted bladder. They were grasped, freed by rotation, and 
extracted one after the other. They showed on extraction two freshly broken sur- 
faces, corresponding to as many pedicle-like projections, branching into two diverti- 
cle's, each containing a separate calculus. One of these calculi was extracted, the other 
and smaller one was left behind, as the patient's poor condition verging on collapse 
did not justify continuation of the operation. The patient did not rally from the col- 
lapse, and died three hours after the completion of the lithotomy. 

The suprapubic incision gave free access to the bladder, and enabled the 
author to conduct the search and extraction of the calculi under the guid- 




Fig. 128.— T-shaped drain- 
age-tube for suprapubic 
cystotomy. (Trende- 
lenburg. ) 



SPECIAL APPLICATION OF THE ASEPTIC METHOD. 165 

ance of the eye. Removal or even the finding of the encysted calculi would 
have been utterly impossible from a perineal wound. Weight of calculi, one 
ounce, five drachms, and twenty grains. 

Case II. — Mr. Adolph W., plumber, aged fifty-six. Vesical trouble of three years' 
standing. Urine slightly acid, turbid, containing much pus, but no casts. March 30, 
1887. — Exploration of the very irritable bladder with the stone- searcher yielded no 
positive result. April 18, 1887. — On exploration in ether anaesthesia, stone was found. 
A Thompson lithotrite being introduced, a large stone was grasped, and on rotation 
was felt to grind against another calculus. Suprapubic lithotomy. Extraction of three 
stones, each weighing about forty-three grammes, their aggregate weight being four 
ounces and three grains Troy weight. April 20th. — Temperature, 100*5° Fahr. ; urine 
clear, acid, containing no blood ; its daily quantity eighty ounces. April 23d. — Patient 
was allowed to occupy the supine position. April 25th. — The drainage-tube was with- 
drawn and the packing removed. A soft catheter was introduced by the urethra, and 
the bladder was irrigated through it. The catheter was left in the bladder ; the ex- 
ternal wound was repacked. Temperature, 98*5° Fahr. May 1st. — Thrombosis of 
right femoral vein, apparently due to defective circulation caused by confinement. 
The right lower extremity enormously increased in size. Treatment: Elevated post- 
ure; later on, moist packing, and elastic compression by Martin's bandage. May 25th. 
— Lithotomy wound nearly closed ; passed some water through urethra. June 4th. — 
Lithotomy wound closed ; urination normal. Patient up and about most of the time ; 
oedema of thigh fast diminishing. June 20th. — Swelling of thigh almost gone ; patient 
discharged cured. July 25th. — General condition excellent. Patient entirely recov- 
ered. 

Case III. — Mr. Meyer B., liveryman, aged thirty-nine. Symptoms of very acute 
cystic catarrh of four months' duration, causing the loss of fifty pounds of flesh. 
Almost constant desire of and very painful micturition, the acid urine containing 
blood, pus, some mucus, uric acid, and oxalate-of-lime crystals. The prostate was 
very painful on touch, but not appreciably enlarged. The patient had become morphi- 
ophagous, and was thoroughly demoralized. Stone was searched for unsuccessfully 
by a surgeon. June 17, 1886. — Suprapubic cystotomy at Mount Sinai Hospital. No 
stone was found, but the mucous membrane of the bladder presented a most marked 
state of hyperaemia and thickening, profusely bleeding at the slightest touch. The 
inflammation was most pronounced about the trigonum and the neck of the bladder, 
where the reddening and tendency to haemorrhage were most intense. Trendelen- 
burg's T-shaped drainage-tube was inserted, and the case was treated in the lateral 
position. The cystic irritation ceased at once, the blood and pus in the urine dimin- 
ished, and morphine was discontinued. July 17th. — The patient was removed to his 
home, where he made a rapid and perfect recovery. In March, 1887, a slight degree 
of catarrh of the neck of the bladder was cured by irrigation with permanganate-of- 
potash lotion. The patient remained well ever since then. 



28 



PART II 



ANTISEPSIS 



CHAPTER VI. 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 

SUPPURA TION. 



TREATMENT OF 



I. THE CAUSE OF SUPPURATION OR PHLEGMON. 

It would far transcend the limits of these essays to enter into a detailed 
presentation of all vegetable organisms known to lead a parasitic existence 
in the living human body. But a few glimpses into this new world of 
beings, more or less hostile to human health and life, may be welcome 
to the busy practitioner, who lacks time or opportunity for independent 
research. 

Rosenbach's classical investigations have revealed the fact that the most 
common source of suppuration is the implantation and thriving in the living 
human tissues of a minute globular fungus or micrococcus, called from the 






Fig. 129. — Microscopical as- 
pect of staphylococcus au- 
reus and albus. (Under 
the microscope their ap- 
pearance is identical.) 
(From Rosenbach.) 



"%, 



Fig. 130. — Streptococcus pyogent 
(From Kosenbach ) 



©&o© 







Fig. 131. — Chain - coccus 
of erysipelas (Fehleisen). 
(From Kosenbach.) 




Fig. 132.— 
trescence 
bach.) 



Bacillus of pu- 
. (From Rosen- 



■8flS 






Fig. 133. — Bacilli taken from a pu- 
trid bone-abscess in general sepsis 
(962 diameters). (From Kosen- 
bach.) 



Fig. 134. — Bacilli from 
emphysematous gangrene. 
(From Kosenbach.) 



golden yellow color of the mold it forms on a peptonized meat-agar culture- 
soil, "Staphylococcus pyogenes aureus" or the golden grape-coccus. It is 
called grape-coccus (staphyle, grape) on account of the agminated or bunched 
arrangement of the single cocci that compose a colony. (Fig. 129.) 



170 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




This coccus is found in almost all forms of acute suppuration — in 
phlegmon, glandular abscesses, and in acute, infectious osteomyelitis. By 
certain methods of manipulation, a pure or unmixed culture of this fungus 
can be raised upon glass plates covered with a film consisting of a mixture 

of peptonized meat-jelly 
and agar agar, a vegeta- 
ble form of gelatin. This 
mold resembles in struct- 
ure the common form of 
mold dreaded by house- 
keepers, only it has a 
deep orange color. It 
has the peculiarity of 
thriving upon the living 
human tissues, causing 
their inflammation and 
ultimate death. (Plate I, 
Fig. 1.) 

Another form of grape- 
coccus, not so common 
as the preceding one, and 
appearing either alone or 
associated with the gold- 
en grape-coccus, is Rosen- 
bach's " Staphylococcus 
pyogenes albus." It can not be distinguished from the yellow coccus under 
the microscope, but the mold produced by pure culture is easily recognized 
by its pearly white color. (Plate I, Fig. 2.) 

Both forms of grape-coccus have the clinical peculiarity of causing well- 
localized foci of phlegmon. All tissues within a certain area become uni- 
formly permeated by the grape-coccus. They coagulate, then emulsify, and 
the result is a distinct abscess. 

Another form of micro-organism — Rosenbach's " Streptococcus pyogenes " 
on pus-generating chain-coccus — is so called on account of the arrangement 
of the single globular cocci in more or less elongated chains. (Fig. 130.) Its 
peculiarity is to rapidly extend along the lymph-spaces and lymphatic ves- 
sels. Its emulsifying property is not as pronounced as that of the grape- 
coccus, but it may become very destructive to the tissues by rapid infiltra- 
tion along the lymphatics, causing progressive gangrene. The peculiarity 
of extending along the course of the lymph-vessels, as well as its micro- 
scopical appearance, testify to its close morphological relation with the 
streptococcus, or chain-coccus of erysipelas, discovered by Fehleisen. (Plate 
I, Fig. 3, and Plate II, Fig. 4; then Fig. 131.) 

Pure cultures of the pus-generating streptococcus and the coccus of ery- 
sipelas differ very distinctly in several important points (see Plate II, Figs. 
4 and 5), but microscopically they can not be distinguished. 



Fig. 135. 



-Bacilli of putrefaction and diverse forms of cocci 
in putrid blood. (Koch.) 



Plate I. 




Fig. 1. — Pure culture of gold-colored grape-coccus of suppuration from a furuncle of the 

lip, on meat-peptone-agar, seen by reflected light. 
Fig. 2. — White grape-coccus by reflected light. 
Fig. 3. — Chain-coccus of pyaemia by reflected light. (From Rosenbach.) 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 



171 



-i^>& sjjfr MStr * * " 



None of the pus-generating cocci cause what is commonly called putres- 
cence. Decomposition of tissues, accompanied by the production of foul 
odors, is always due to the 
fermentative action of di- 
verse forms of elongated bod- 
ies, called bacilli or bacteria. 
Plate III, Fig. 8, shows a 
pure culture of the " Bacil- 
lus saprogenes," or bacterium 
of putrescence. Fig. 9 is a 
pure culture gained from an 
osteal focus in putrid com- 
pound fracture with fatal 
septicaemia. (Figs. 132 and 
133.) 

The accompanying chro- 
molithographs were careful- 
ly copied from Rosenbach's 
monograph, and give a very 
life-like image of the several 
molds or cultures. 

On account of their ex- 
cellence and truthfulness, a 
number of Koch's renowned microphotographs, illustrating various forms 
of microbial growth, have been here reproduced. 







Fig. 1S6. — Bacteria of blue pus (700 diameters). (Koch.) 



II. PORTALS OF INFECTION. 

It is safe to assume that, without exception, all forms of suppuration 
owe their origin to infection from without. The portals through which 

the pyogenic organisms 
known as cocci and bac- 
teria enter the system 
are, on one side, the le- 
sions of the outer integu- 
ment ; on the other, le- 
sions of the mucous lin- 
ing of the digestory, re- 
spiratory, and urogenital 
apparatus. The infection 
of larger accidental or 
surgical wounds has been 
treated of in the preceding chapters. Infection through minimal lesions of 
the skin or mucous membranes and its sequelae will now receive attention. 

1. Infection through Lesions of the Skin.— The popular tenet that a 
wound that bleeds well heals well, is based on correct observation. Sharp 




Fig. 137.— Human kidney in pyelo-nephritis 
urinary canal rilled with cocci (700 diamet 



In the center, 
xrs). (Koch.) 



172 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

haemorrhage is very apt to dislodge and carry off particles of filth deposited 
in the wound from without at the time of the injury ; and, further, it sig- 
nifies an abundant blood supply, good nutrition, hence prompt union. An- 
other point of importance is, that wounds that bleed profusely generally 
come under the care of a physician, and will receive at once proper atten- 
tion and protection from further injury. 

Small abrasions, lacerations, or punctured wounds that bleed very little, 
or not at all, have deservedly a bad reputation. If the injuring instrument 
or object does not inoculate the wound with filth, and subsequent infection 
is prevented by proper measures, healing will proceed without interruption. 

But, as a rule, these wounds are neglected from the outset, because there 
is scanty or no haemorrhage. The sharp-edged tool of the mechanic, or 
the pointed object handled in the daily vocation of the laboring man, is 
very rarely clean. In certain occupations, as that of the butcher, anato- 
mist, or cook, the hands are frequently injured while in contact with foul 
organic substances, and the injuring force will at the same time inoculate 
filth. No haemorrhage following, and the pain being insignificant, the 
matter is lightly passed over, and work proceeds without interruption. The 
cleansing effected by haemorrhage is absent, the small orifice of the skin is 
soon filled by lymph and obliterated, and we have to deal with a hermetic- 
ally sealed focus containing filth, leavened by a certain number of micro- 
organisms, that at once must and do begin to develop and multiply, causing 
a destructive purulent inflammation. 

Not all of these small injuries are infected from the beginning. They 
may and, as their frequent spontaneous healing proves, are often enough 
aseptic. 

As a matter of fact, they do well at first, and as long as the patient takes 
care of them. But if, as often happens, the protecting scab is reinjured, 
and infection by contact with foul matter follows, the consequence is sup- 
puration. 

Note. — Inflammatory lesions of the skin are fruitful sources of infection, among them 
eczema the foremost. The intense itching leads irresistibly to scratching, and the small excoria- 
tions thus produced are often the portals of infection. 

2. Infection through Lesions of the Mucous Membranes. — Less numerous 
than the lesions of the skin, yet productive of frequent mischief, are the 
traumatic and inflammatory lesions of the mucous membranes. Slight 
injuries to the lips, tongue, buccal and faucial mucous membrane are very 
common. In most cases a profuse flow of saliva is instantly produced by 
a painful injury, and, if haemorrhage be also present, infection rarely takes 
place. Healthy oral cavities and their adnexa are especially exempt from 
infectious processes following injuries. Even gunshot wounds of these parts 
can heal without suppuration under favorable circumstances : 

Case. — E. L., aged eighteen, admitted to Mount Sinai Hospital, December 7, 1884, 
with suicidal fresh pistol-shot wound of the tongue, extending from the tip backward 
to the left side of the base, dividing the organ in two unequal parts. Gunshot perfora- 



Plate II. 




Fig. 4. — Culture of chain-coccus from a case of acute progressive gangrene. Transmitted 

light. 
Fig. 5. — Chain-coccus of erysipelas (Fehleisen). Transmitted light. 
Fig. 6. — Chain-coccus of erysipelas by reflected light. (From Rosenbach.) 






NATUEAL HISTORY OF IDIOPATHIC SUPPURATION. 173 

tion of the pillars of the fauces of the left side ; gunshot wound of the posterior pharyn- 
geal wall, the point of entrance situated just back of the faucial pillars of the left side, 
about an inch and a quarter from the median line, all of these injuries being produced 
bj a bullet of 22 mm. caliber. A second non-penetrating gunshot wound on the fore- 
head without a point of exit. Free haemorrhage from the tongue, and also a stream 
of arterial blood from the pharyngeal wound. The latter being in close vicinity to the 
left internal carotid artery, the left common carotid was tied at once as a preventive 
measure, mainly with a view to the possibility of subsequent suppuration and second- 
ary haemorrhage. The perfect condition of the teeth and oral mucous membrane was 
noted. The lingual wound was lightly rubbed over with a small sponge dipped in 
iodoform-powder ; the pharyngeal wound was not probed, and hourly irrigation of the 
oral cavity with weak salt water was practiced. Profuse sweating, perhaps due to 
reflex vasomotor disturbance, set in, and persisted for about forty- eight hours. The 
febrile movement was very slight, and both the operation wound and the gunshot 
wound on the forehead, being redressed on December 15th, were found healed and 
dry under their iodoform dressings. The lesion of the tongue was found granulating 
and contracting, the perforation of the pillars of the fauces nearly closed, the point of 
entrance in the posterior pharyngeal wall firmly occluded by a fresh-looking blood- 
clot. Breath odorless. December 21st. — The flattened ball removed by small incision 
from the top of the head, where it could be felt beneath the skin. The entire track 
of this projectile had literally healed without suppuration. The pharyngeal wound 
found also cicatrized over, the ball being imbedded near and below the left transverse 
process of the atlas, in close proximity to the vertebral and internal carotid arteries. 
The head was held inclined to the right side, erection of the spine and its flexion to 
the left being impossible on account of the intense pain caused by the attempt. This 
functional disturbance diminished to such an extent within a few months that the con- 
templated extraction of the small projectile was abandoned. 

Had the patient's oral cavity been fonl from putrid processes accompany- 
ing an acute or chronic oral catarrh, due to dental caries or other causes, 
suppuration of the pharyngeal wound would have been very probable. The 
danger would have been very much graver on account of the possibility of 
extension of the suppuration and the likelihood of uncontrollable secondary 
haemorrhage. A probing of similar wounds without a clear and necessary 
object in view is always a dangerous and invariably useless step, and should 
be refrained from under almost all circumstances. We may use a clean 
probe, and the probe may not be the carrier of infection ; but its introduc- 
tion will break down the blood-clot, the natural barrier provided by the 
organism itself against infection, and the probe will leave behind an open 
channel for the entrance of possibly fetid oral mucus into the narrow wound. 

Next in frequency to the inflammations in and about the oral cavity 
and its adnexa are those due to injuries and other lesions about the anal 
and uro-genital orifices. 

III. ENTRANCE, PROGRESS, AND LOCALIZATION OF THE 

INFECTION. 

As long as the integrity of the epidermis is preserved, no infection from 
without will take place. The integrity of the epithelial covering of the 
mucous membranes does not seem to have the same protective power as the 

24 



174 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



epidermis. This may be explained by the fact that slight injuries of the 
mucous lining are produced much more easily than those of the skin, and 
are not readily ascertained on account of the normally moist condition of 
the parts. 

As formerly stated, the slightest denudation, not deep enough to cause 
haBmorrhage, and just productive of a slight exudation of serum, offers a 
favorable point of entrance to the virus in the patulous orifices of the 
lymphatic vessels or lymph-spaces, thus exposed by the injury. 

In lacerations or punctured wounds the infective agents are very 
often deeply inoculated with the point of the injuring article — that 
is, they are at once deposited in close vicinity to deep-seated lymph- 
vessels. 

In the more superficial forms of injury, the implantation of the virus 
occurs only in the neighborhood of more superficial lymphatics, and its 
transmission to the deeper lymph-vessels is accomplished 
by forces which govern the flow of lymph from the pe- 
riphery to the center. Aside from the normal current set- 
ting toward the thoracic 
duct, external forces and 
the play of the volun- 
tary muscles have an im- 
portant part in hasten- 
ing the flow of lymph. 
So, for instance, the 
pressure exerted upon 
the lymphatics of the 
palm by the frequent 
and vigorous grasping 
of a tool wielded for a 
long time with great 
force, will undoubtedly 
help to propel the con- 
tents of the peripheral lymphatics toward the larger, more deeply situated 
lymphatic trunks. Or the vigorous contractions of the muscles during 
mastication will undoubtedly empty the adjacent lymphatics centerward, 
their action being aptly comparable to that of a force-pump. 

What was formerly denoted as external mechanical irritation is nothing 
but this forcing of pus-generating substances into the open lymphatics by 
friction or other pressure due to exercise. 

The direction and extent of the spread of the infection by the lymphatics 
are prescribed by the anatomical arrangement of the lymph-vessels of the 
region concerned. Thus, on the palmar aspect of a finger, the poisoning 
will rapidly extend to the periosteum, as the lymphatics all tend that way. 
In the vicinity of lymph-glands, the infection will promptly extend to them, 
an intervening lymphangitic streak often clearly denoting the route by 
which it traveled. 




Fig. 138. 



-Bacilli of anthrax and streptococcus 
(700 diameters). (Koch.) 



Plate III. 




Fig. 7.— Mixed culture of golden and lemon colored and of white grape-coccus from a 

case of empyaemia. Reflected light. 
Fig. 8. — Common organism of putrescence. Bacillus saprogenes. Reflected light, 
Fig. 9. — Bacillus saprogenes from a focus of septic compound fracture. Septicemia. 

Reflected light. (From Rosenbach.) 



NATUEAL HISTOEY OF IDIOPATHIC SUPPUEATION. 175 

The varying intensity of the infection, dependent on hitherto unknown 
and varying fermentative qualities of different cultures of micro-organisms, 
will also greatly influence the rapidity and virulence of the inflammatory 
process. So much is well established that the intensity of the infection 
depends, first, on the virulence of the invading culture of bacteria ; secondly, 
on the quantity of fungi absorbed ; and, thirdly, on the power of resist- 
ance — that is, the state of health of the invaded organism. 

Mechanical Irritation. — Mechanical irritation by foreign substances 
imbedded in tissues, such as bullets, splinters of glass, or a broken-off point 
of a knife-blade, is also a myth in the old meaning of the phrase. They 
never cause suppuration unless infectious substances — that is, microbial 
filth — be adherent to them at the time of their being deposited in the tis- 
sues. They may cause pain by pressure upon nerves, or may interfere 
with the play of a joint or a muscle, but, as a rule, never will cause in- 
flammation or suppuration. Well-disinfected steel nails, driven by mallet 
through femur and tibia after exsection of the knee-joint, are unhesitat- 
ingly left imbedded for thirty or more days, never causing any irritation 
(see Exsection of Knee- Joint, page 287.) 

Case. — In 1882 a young blacksmith presented himself in the surgical division of 
the German Dispensary. An angular foreign body could be distinctly felt under the 
skin on the palmar aspect of the right forearm, midway between elbow and wrist, 
causing pain by impinging. The body had appeared only since a few weeks. Near 
the carpus a transverse cicatrix was to be seen, and the patient explained that he was 
cut there during a drunken brawl two years ago, and that a surgeon had tied an artery 
and sewed up the wound, which had healed without suppuration. Ever since then he 
had worked at his trade without any inconvenience until within a few days. From 
the incision made over the projecting body, a blackened knife-blade, four inches long 
and five eighths of an inch wide, was extracted, to the greatest astonishment of the 
patient. The small wound closed promptly. 

Here we saw a massive, sharp-edged foreign body lie imbedded for two 
years between the muscles of the forearm without any inconvenience to the 
patient, until the angular base of the blade had worked out under the skin. 
Why did it not cause suppuration ? Apparently the blade must have been 
newly ground, or at any rate very clean, when it broke off in the arm of 
our blacksmith. Had a considerable amount of infection been carried along 
with it at the time of the injury, its presence would not have been over- 
looked so long. 

Bead organic substances, as, for instance, blood, or cubes of animal tis- 
sues, such as muscle, tendon, or portions of liver or bone, were taken from 
a freshly killed animal, and introduced into the abdominal cavity of a num- 
ber of other rabbits under strict antiseptic precautions. In a very large 
proportion of cases no reaction whatever followed. The animals being- 
killed, it was found that blood was absorbed outright ; that muscle, liver, 
tendon, and bone were encapsulated ; and that their structure was gradually 
invaded by granulation tissues — disintegration and final absorption follow- 
ing after a while, proportionate to the density of the implanted bodies. In 



176 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

cases where the ordinary aseptic measures had been omitted, septic purulent 
peritonitis followed as a rule. 

Note. — The most remarkable of Dr. H. Tillmann's experiments (Virchow's " Archiv," Bd. 
lxxviii, 1879) is that concerning a rabbit, in the abdomen of which an entire rabbit's kidney was 
deposited without causing any harm whatever. The animal being killed forty-seven days after 
the operation, the implanted kidney was sought for in vain, as it had disappeared by absorption, 
the only vestige of its former presence being a spot of tough cicatricial tissue, denoting the 
locality where the foreign body was attached by exudations. 

This experimental observation is fully borne out by the experience gained 
in numberless ovariotomies, where massive pedicles, dead through stoppage 
of their circulation by ligature, are dropped back harmlessly in the perito- 
naeum, to be finally absorbed — that is, they will do no harm if a culture 
of bacteria is not deposited on them by the operator. 

Chemical and Caloric Irritation. — The common experience that certain 
acutely irritating substances, as, for instance, croton-oil, oil of cantharides, 
turpentine, concentrated solutions of corrosive sublimate, and others, 
brought in contact with living tissues, always would produce suppuration, 
represented a serious gap in the theory of the microbial origin of suppura- 
tion. If invariably proved, it would be more than a defect, as it would 
positively contradict the thesis that suppuration is exclusively and always 
the result of the development of micro-organisms. The experiments of 
Councilman,* who introduced under the skin of animals small glass globes 
filled with sundry irritating substances, and then crushed them, all led to 
suppuration. Scheuerlen f and Klemperer,| however, in going over Coun- 
cilman's experiments, showed that his procedure was faulty, inasmuch as 
sufficient precautions had not been taken to exclude the introduction of 
microbes along with the croton-oil, etc. They moreover positively demon- 
strated by a very large number of successful experiments that, whenever 
thorough aseptic cautelae were observed, suppuration never followed the in- 
troduction of even very considerable quantities of the mentioned substances. 
Small quantities caused some exudation of plasm, and then were absorbed 
outright. Afterward the fragments of the glass receptacle were found im- 
bedded in a film of new-formed connective tissue. Larger quantities of 
croton-oil, for instance, caused a coagulation necrosis of a limited mass of 
tissue, which was found dense, bloodless, and of a yellow color. These 
nodes of necrosed tissue were gradually absorbed, suppuration never follow- 
ing the experiment. This fact is in full accord with other incontestable 
facts of the same character, as, for instance, the absorption of necrosed 
ovarian stumps in the abdominal cavity if there be no microbial infection 
present. 

Caloric irritation, or even an outright destruction of tissues by exces- 
sive heat, presents a similar state of things. As long as microbial infection 
is successfully kept away from the exudations in burns of a milder charac- 

* Virchow's "Archiv," 1883, vol. xcii, p. 217. 

f " Archiv f iir klin. Chirurgie," vol. xxxii, p. 500. 

\ Prize essay, Berlin University, "Zeitschr. fur klin. Med.," 1885, vol. x, p. 158. 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 177 

ter, and from the eschar and exudations in severer forms, no suppuration 
will follow. The modern use of the thermo-cautery in the peritoneal cavity, 
in joints, and, as a matter of fact, in wounds of the most various character 
and of all anatomical regions, is followed by uninterrupted union in all 
cases where, at the same time, adequate aseptic measures are employed. 
An eschar or a mass of dead tissue, whether produced by ligature, or chemi- 
cal corrosion, or red heat, will never assume the irritating character of a 
"foreign body/' in the meaning of the term as presented by the tenets of 
an older pathology, if the decomposing action of the presence of micro- 
organisms is excluded by proper measures. 

The behavior of superficial burns of the skin is fully in accord with the 
facts just presented. 

If a bleb be raised, and is left unbroken and dry, its contents will be 
absorbed, and the epidermis will settle back into its normal relation to the 
cutis. It will turn into a dry scale, and will peel off within ten to twelve 
days, exposing the tender new epidermis. 

How different is the course of a burn if the epidermis is torn off by acci- 
dent or intentionally, and the exudations are thus exposed to the invasion 
of micrococci ! If the surgeon do not employ timely disinfection and the 
application of a protective dressing, suppuration of the exposed cutis, with 
all its accompaniment of pain, long-continued granulation, and a very tardy 
healing, will follow. 

IV. DEVELOPMENT OF PHLEGMON. 

From the moment that a sufficient quantity of active fungi have estab- 
lished themselves within the living tissues, remarkable local and general 
phenomena develop, known under the name of inflammation and septic 
fever. 

Our object is not research into, but rather a lucid explanation of, the 
essence of inflammation, as understood and accepted by contemporary au- 
thorities. Hence a brief sketch of the leading features of the process is 
deemed sufficient. 

Micrococci find a most favorable pabulum in dead or devitalized organic 
substances. The living tissues offer a decided resistance to the ravages of 
the micro-organism. The spontaneous limitation and occasional unaided 
cure of some forms of suppurative inflammation prove this assertion. 

Bacteria can not thrive on the products of decomposition : they need 
for their sustenance dead but undecomposed albuminoid substances. As 
soon as the supply of dead animal tissue is exhausted, the micro-organisms 
starve and perish. Their spores or seeds are left behind dormant, but will 
become active if fresh pabulum is offered under favorable circumstances. 

This explains the fact that fresh cadavers or animal substances in the 
recent stages of putrescence are much more infectious than those that are in 
a progressed state of decomposition. The varying intensity of different cases 
of infection seems to depend in a great measure upon the varying degrees 



178 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of vitality of different microbial cultures. It seems to admit little doubt 
that the great majority of dangerous wound infections are brought about by 
the importation of considerable masses of very active, rapidly proliferating 
micro-organisms in the shape of "lumps of dirt," as Lister graphically puts 
it, taken from various sources of recent putrescence, so abundant in all 
human surroundings. The dry spores floating in the air will be easily taken 
care of by the living tissues, if pollution of the wound by gross dirt — that 
is, masses of organic matter in active decomposition — is avoided. 

Every injury causing a wound destroys the vitality of those cells that 
lie in the direct path of the cutting or lacerating object. The blood and 
lymph exuded from the vessels coagulate, and also represent dead matter. 

If a number of active micrococci are implanted into the bottom of the 
wound, they will at once multiply, using the blood-clot and its extensions 
into the blood-vessels, together with the adjacent dead or devitalized tissues, 
as a welcome soil for their development. This fermentative decomposition 
produces from its very beginning certain alkaloids or chemical, extremely 
poisonous substances, the ptomaines, that are very diffusible. By dint of 
this diffusibility, the adjacent vasomotor nerves at once come under their 
toxic influence, as the result of which their strong dilatation ensues, which 
becomes manifest in the shape of an active hyperwmia, "rubor." 








Fig. 139.— Bacilli of anthrax (700 diameters). 
(Koch.) 



Fig. 140. — Formation of spores in anthrax 
bacilli (700 diameters). (Koch.) 



The blood passing through the adjacent arterioles and capillaries seems 
also to become altered ; the red blood-corpuscles become packed and finally 
stagnate in the capillaries and smaller arteries. The walls of these vessels, 
including the veins, lose their impermeability, and a number of white and 
often red blood-corpuscles emigrate into the surrounding tissues, densely 
infiltrating their interstices, thus producing the characteristic sivelling, 
"turgor " 

As a consequence of the increased blood-supply, possibly also of the 
active chemical process, a marked increase of the local temperature is ob- 
served — "color." And, if we add that pain of the parts thus affected is 



NATUEAL HISTORY OF IDIOPATHIC SUPPURATION. 179 

never absent, we have completed the classical cycle of the four cardinal 
symptoms of inflammation — " rubor, color, turgor, dolor" 

Note. — The causes of local pain may be several. The initial pain is very likely due to a 
direct influence of the ptomaines upon the sensory filaments. Direct pressure caused by the 
dense infiltration may also have some influence ; but the most acute pain is undoubtedly effected 
by the actual destruction of the nerve-tissue during the advanced stages of suppuration. 

Stagnation and dense infiltration finally produce a very high degree of 
tension, leading to compression of larger afferent vessels. The infiltrated 
portions, devitalized by suppression of the normal circulation, readily suc- 
cumb to the inroads of the millions of micro-organisms, and actual necrosis 
rapidly follows. The last stage of textural destruction is the final liquefac- 
tion of the tissues and infiltrating leucocytes, aided by the exudation of 
large quantities of lymph-serum from the adjacent unobstructed blood-ves- 
sels, and thus the formation of an abscess or a cavity filled with lymph- 
serum, myriads of dead white blood -corpuscles (pus-cells), and quantities of 
shreds of necrosed tissues, is accomplished. 

The veins also participate in the disturbance. Coagulation of their con- 
tents — thrombosis — takes place, and existing stagnation is materially aug- 
mented. 

The deleterious part played by thrombi in the causation of metastases 
will be later mentioned. 

When a septic inflammation of sufficient extent and intensity has been 
well advanced, the great tension of the parts will necessarily cause an over- 
flow of the most diffusible contents of the focus into the surrounding effer- 
ent vessels — the veins and lymphatics. The ptomaines, thus entering the 
general circulation, will at once produce systemic intoxication, manifested 
by a very marked rise of the body-heat, rigors, sickness, headache, delirium, 
and general dejection — in short, a deep-going alteration of the nervous 
system, known as septic fever. 

V. SPREAD OF SUPPURATION. 

The way of the extension of septic textural destruction is twofold. It 
takes place, first, by a direct infiltration of the tissue-interstices by columns 
and hosts of the immensely prodigious micrococci — that is, by an immedi- 
ate growth and extension of the microbial colony ; and, secondly, on the 
way of the lymphatics, openly communicating with the focus of suppura- 
tion. Into these, bacterial masses, or pus charged with micrococci, are 
forced by the hydrostatic pressure exerted by the tension within the abscess. 

If the parts affected are composed of loose tissues, the spread will be 
rapid and extensive : if the parts are dense, the inflammation will remain 
localized as long as the density of the tissues (fasciae, for instance) will resist 
the pressure of the secretions. But, as above mentioned, this very pressure, 
or tension, involves another great danger. The afferent blood-vessels become 
thereby occluded, and the resulting stagnation generally leads to extensive 
necrosis. 



180 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

As long as new areas of tissue become infected through the lymphatics, 
constant high fever and increase of the local symptoms is the rule. An 
incision laid through the parts at an initial stage of the process will expose 
a honeycombed mass of tissue, containing a number of small foci, some of 
them confluent, and all filled with pus, the intervening substance being 
discolored, pale, or more or less broken down and softened, or sloughed. 

In direct proportion with the spread of the infection and the multiplica- 
tion of suppurating foci, is the magnitude of necrosing areas, occasionally 
involving an entire limb. Organs of scanty vascularity, as, for instance, 
fasciae, tendons, and bone, are the first to succumb. 

The microbial colony begins to show signs of exhaustion in most cases 
after a more or less prolonged period of florescence. The parasite becomes 
less prolific ; its direct ingrowth into the tissues is less and less active, and 
the life of the white blood -corpuscles, densely infiltrated into the marginal 
parts of the abscess, is not compromised by their invasion with micrococci. 
They are not converted into pus, but withstand the attack of the parasites 
and remain a mass of embryonal connective tissue, that forms a dense wall 
inclosing the suppurating cavity. This embryonal connective tissue uni- 
formly permeates all the adjacent parts, among others the lymphatics and 
thrombosed veins, forming a more or less effective barrier to the extension of 
the septic process and to the absorption of deleterious soluble substances into 
the general circulation. 

This self-limitation of the spread of septic destruction is generally 
marked by a remission of the intensity of the general and, in a measure, of 
the local symptoms. At this stage, according to ancient notions, the abscess 
has matured. 

Note I. — For obvious reasons, the incision of a matured abscess is generally followed by a 
rapid healing of the cavity. The detachment and liquefaction of the contents of the abscess are 
well completed, the extent of the process is well rounded off, as it were, by the wall of newly 
organized connective tissue, and repair can commence under favorable circumstances. 

Nevertheless, it must be strongly urged that the most dangerous abscesses never ripen — that 
is, show no tendency to self-limitation— and that the measures ordinarily employed for maturing 
them, such as vigorous poulticing, only tend to intensify their malignity, and to cause irrepara- 
ble damage, that an early incision might have averted. A case vividly illustrating the pernicious- 
ness of thoughtless poulticing is quoted on page 234. 

Note II. — Not every bacterial infection leads to suppuration, although the rule suffers very 
few exceptions indeed. One of the exceptions is illustrated by the following : Case. — I. N., laborer, 
aged twenty-four, was admitted to the German Hospital in March, 1885, with a very painful, 
hard, and massive swelling of the axillary contents, the skin being oedematous and angry-looking. 
High fever and a good deal of sickness were observed, so that pus was thought to be indubita- 
bly present. An incision was declined, whereupon a poultice was ordered, with the expectation 
that it would hasten the process by stimulating suppuration. For a day or two the intensity of 
the symptoms increased rather than otherwise, several sharp chills followed with profuse sweat- 
ing, after which came a marked improvement of all the appearances of the case. The redness 
and swelling diminished, the fever disappeared, and the patient left the hospital cured, glorying 
in his triumph of endurance over diagnostic acumen. 

To explain such cases, it is necessary to assume that, under the powerful stimulation of 
the local circulation by the cataplasm, the products of bacterial fermentation, bacteria, or even 
pus itself, are washed away by the lymph-current into the general circulation, where the pto- 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 181 

mai'nes provoke constant or explosive symptoms of general intoxication, such as high fever or 
severe chills ; the bacteria themselves, however, perish, the living oxidized blood forming an 
unfavorable pabulum for their existence and propagation. In accord with this theory is the 
well-known fact that wounds of very vascular tissues, such as those of the face, for instance, 
will heal without suppuration even when there is a good deal of inflammation of their edges, 
with pain and fever, denoting the presence of a certain amount of septic infection. The poorer 
the blood-supply of a part, the greater the destruction wrought by an infectious process. 

If the abscess is not evacuated at the stage of maturity through a fortu- 
nate spontaneous or an artificial opening, the relief felt by the patient will 
be a short-lived one. The marginal wall of embryonic connective tissue — 
that is, the area of granulations — will continue to shed lymph and detached 
leucocytes into the abscess cavity. The intramural pressure will steadily 
increase until it rises to such a degree as to overcome, on hydrostatic prin- 
ciples, the resistance of the soft plugs of living leucocytes, which occlude 
the orifices to the adjacent connective-tissue planes and lymphatics or veins. 
One or another of these offering the least resistance, will be forced out of 
the way, and a new invasion of hitherto unaffected regions results, with a 
repetition of all the initial local and general symptoms, marking an exten- 
sion of the process. 

Xote. — The notion that the law of gravity alone regulates the spread of abscesses is an erro- 
neous one, as it is well known that many forms of suppuration extend in a diametrically opposite 
direction to the force of gravity. The local spread is prescribed by the direction of the loose 
connective-tissue planes separating and connecting the different organs, and is mainly influ- 
enced by hydrostatic law. Perforation always takes place where resistance is the least. 

The infiltration of the tissues by micrococcal colonies sometimes extends 
to the close vicinity or into the very walls of larger veins. Thrombosis is 
the direct result, and, if the microbial invasion includes the thrombus, after 
the detachment of the slough of the vein and the liquefaction of the throm- 
bus, a direct communication of the general circulation with the abscess 
cavity may be established. The slightest external pressure may serve to 
throw enormous masses of pus and micro-organisms into the general circula- 
tion at this critical period, causing rapid death by explosive septicaemia. 
In these cases the microscope will demonstrate the presence of micrococci 
in the entire blood-mass. 

In other cases, either spontaneously or in consequence of active move- 
ments or external manipulations, a portion of a septically infected thrombus 
may be detached. The blood -current will at once carry it into the right 
auricle and ventricle, whence it will find its way into one or another branch 
of the pulmonary artery, to be there arrested in the shape of an embolus. 

Around this a haemorrhagic infarction of the adjacent pulmonary tissues 
will form, within which a new bacterial colony will become established, 
leading to the formation of a secondary or metastatic abscess. Its appear- 
ance is always signalized by a severe rigor. 

Thrombosis of adjacent pulmonary veins, and detachment of portions of 
the new thrombus, followed by its transportation into the left side of the 
heart, and hence into distant smaller-sized arteries of the body, will lead to 
25 



182 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

a repetition of the metastatic process and its febrile accompaniment, until 
a number of joints, lymph-glands, the liver, in fact, almost all the organs, 
become the seat of secondary abscesses. 

This is the classical type of well-developed pycemia, formerly so common 
in all surgical hospital wards, but now become a rare phenomenon wherever 
the leaven of the Listerian spirit has permeated surgical practice. 

This form of microbial colonization of the entire human body baffles 
every plan of treatment, and almost invariably leads to the destruction of 
the organism. It is as good as incurable, but it can be prevented ; hence it 
is the moral duty of every physician to do everything in his power to avert 
this form of mischief. 

Note. — Recovery of a case of to ell-developed pyosmia is so rare that recording the following 
case seems permissible. The notes were kindly furnished by Dr. A. Caille, with whom the 
author saw the patient in consultation at his home in Williamsburg : 

" Henry Huhn, an elderly man. Enormous carbuncle over left scapula ; necrosis of fasciae 
and subcutaneous connective tissue from clavicle to seventh rib posteriorly, the result of three 
weeks' neglect (poulticing). 

"Energetic treatment (by Dr. Caille) with knife and irrigation (carbolic). Well-marked 
symptoms of pyaemia ; general furunculosis of trunk. 

u August 16, 1880. — Consultation with Dr. Gerster, who advised tonic treatment and daily 
full baths in tvealc bichloride-of -mercury solution, together with frequent irrigations with cam- 
phorated water. Temperatures at this time on an average 102° Fahr. Pulse, 120 to 140. Dysp- 
noea, chills, and sweats. Improvement noticeable, but slow. In September, suppuration of 
almost all the lymph-glands took place within one week, without redness or tenderness, so that 
at one time a tenotomy knife introduced almost anywhere would draw pus. Subsequently exten- 
sive and painful periostitis and abscess at upper third of right tibia developed. About this time 
examination of urine revealed a large percentage of sugar. The patient's diet was properly 
regulated, and his urine was free from sugar five months later. Mr. II. has since been, and is 
to-day (December 23, 1886), in excellent health." 

It will be noticed that a methodical use of a mercuric lotion was advised by the author sev- 
eral years before Kuemmel's and Schede's experiments brought corrosive sublimate so promi- 
nently to the notice of the medical world as an excellent disinfectant. The recommendation 
was based upon the long-known good influence that corrosive sublimate has upon acne pustu- 
losa of the face. Its application in the shape of a full bath suggested itself by the extension of 
the affection to almost the entire skin, and by the enormous difficulty in cleansing and dressing 
the innumerable sores of the patient. Since that time the author has employed the permanent 
bath in another similar case, to the great relief of the patient and his attendants. Twice daily 
the bath was charged with corrosive sublimate (1 : 5,000) for an hour, after which the solution 
was drawn off, and substituted with a weak salicylic lotion. The remarkable relief brought 
about by the immersion of the entire body was due to the circumstance that, first, the frequent 
and extremely painful change of dressings could be dispensed with ; and, secondly, that, accord- 
ing to hydrostatic law, the buoyancy of the immersed body relieved to a very great extent its 
pressure upon the couch spread in the bottom of the bath-tub. The spread of the bed-sores 
ceased. Before his attack, the patient had been in very weak health. After three or four seiz- 
ures by collapse, relieved by increase of the temperature of the bath to 110° Fahr., he suc- 
cumbed to heart failure. 

The contents of the preceding pages have in a rough way illustrated the 
essence of cellular phlegmon, or the suppuration of connective tissue, inele- 
gantly denoted in text-books as "cellulitis." 

For obvious reasons lymphatic glands very often become the seat of 
microbial proliferation. Their direct communication with a numerous set 



NATURAL HISTORY OF IDIOPATHIC SUPPURATION. 183 

of lymphatics and their filter-like structure naturally lead to ready absorp- 
tion and detention of noxious substances. In this characteristic is to be 
sought a by no means insignificant protective quality of the lymphatic 
glands against general invasion of the body by microbial masses. 

The difference exhibited by lymph-gland abscesses in comparison with 
the ordinary forms of phlegmon is due to their anatomical structure and 
situation. Their strong capsule will resist destruction for a comparatively 
long time, thus preventing for a while invasion of the vicinal tissues. But 
the internal tension of a glandular abscess soon becomes very great, and will 
lead to extensive mortification by compression of vessels. 

The anatomical situation of many lymph-gland abscesses, their deep seat 
and close vicinity to large vessels, the pleura, the fauces, and larynx, invest 
them with additional importance, both as regards the danger peculiar to 
their locality, and the technical difficulty of their treatment. 

The skeleton is fortunately a comparatively rare seat of bacterial infec- 
tion. The fearfully dangerous and destructive character of acute infectious 
osteomyelitis, or "bone phlegmon," is due to the rigidity and unyielding- 
nature of the periosteum and bone tissue, which lead to rapid occlusion of 
the blood-vessels, and extensive, often widely disseminated necrosis. The deep 
situation of the bones renders the symptoms of this form of suppuration ex- 
tremely violent and dangerous, and increases the difficulties of treatment. 

Note I. — The so-called habituation of butchers, cattlemen, and anatomists to infection seems 
to be based rather on structural changes of the skin of their hands frequently exposed to con- 
tamination, than to a real habituation, such as is, for instance, brought about by vaccination 
against the small-pox. That the system of these persons does not become hardened or accus- 
tomed to the septic virus is proved by the fact, that phlegmonous processes will readily establish 
themselves, and develop in the ordinary way, if the infection occur elsewhere than on their hands. 
A more plausible explanation of this apparent immunity will be found in the state of the lym- 
phatics of the integument. Having been the seat of frequent more or less intense attacks of 
inflammation, they become obliterated and distorted, as it were, by cicatricial changes in and 
around them. That recent or old cicatricial formations do not possess large-sized lymph-vessels 
is well known, hence absorption through them of corpuscular elements into the deeper lymphatics 
will be difficult and scanty. In short, the chronically inflamed state of the skin covering the 
hands of these persons offers in its infiltrated condition an effective protection against the deep- 
going or massive implantation of micro-organisms through superficial lesions. 

Parallel with this state of things seems to be the well-known fact that children subject to 
frequent attacks of septic tonsillitis or diphtheria rarely succumb to the disease. Penetration 
by bacterial elements of the dense cicatricial tissue left behind by many preceding attacks is 
difficult, and absorption of the ptomaines through the scanty lymphatics is very limited. Hence 
the process soon becomes exhausted through lack of pabulum 10 the microbial growth. A cer- 
tain quantity of viable spores remain imbedded in a follicle, to again develop their activity as 
soon as a simple catarrhal inflammation of the pharynx will have prepared the soil for their 
renewed growth. 

Diphtheria in children who never had been subject to the disease is a much more serious 
matter. Unchanged tissues with open lymphatics are attacked here. The conditions for local 
microbial proliferation and invasion of the tissues, and for absorption and systemic intoxication, 
are much more favorable then, and, as is well known, often lead to unavertable death. 

The comparative safety of all operations performed within the limits of a preceding but 
terminated inflammation — that is, within recent or older cicatricial tissue — is very well known 
to all surgeons. Reamputations, many joint exsections, almost all necrotomies, rarely give any 



184 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

serious trouble, even if the antiseptic measures taken were not very complete. The infection 
of an amputation wound made through healthy tissues is much more serious, and its avoidance 
more difficult, as countless lymphatics and large, newly opened, intermuscular, loosely knit 
connective-tissue planes offer numerous recesses and countless channels for the reception and 
unimpeded extension of infection. 

Therefore the statistics of amputation wounds have been very appropriately selected as a 
uniform and reliable test of the value of the different forms of wound treatment. 

Note II. — Infection through minute injuries to a granulating surface by inoculation of active 
micrococci is the frequent cause of suppurations interrupting the course of repair. Rough treat- 
ment of a granulating wound by tearing off the adherent dressings will necessarily lacerate the 
tender granulations matted into the meshes of the fabric, thus causing minimal haemorrhage. 
If an unclean probe, or finger-nail, or nitrate-of -silver stick, previously used on a virulent case, 
and then applied to the granulations, should carry and deposit some active micrococci into one 
of these minute lesions, an ulcerative process of the granulations will ensue, and, if the ulcera- 
tion extend into adjacent tissues, phlegmon will develop. Granulations should always be covered 
by '■'■protective' 1 '' before the application of gauze or other dressings. 

Conclusions. 

Suppuration is always undesirable and dangerous, and, if possible, should 
be avoided by all means. Its essence is textural destruction and death, and 
systemic intoxication. The phrase "healing by suppuration " is an absurd- 
ity, is misleading to the student, and should be banished from text-books. 
As a matter of fact, healing never takes place while active suppuration lasts ; 
it occurs only after the limitation and termination of suppuration, not by 
it, but in spite of it. 

The expression "laudable pus," as applied to the contents of an abscess 
during one of its stages of spontaneous limitation or maturing, is also mis- 
leading. Pus is never laudable ; it always is a menace to the health and 
integrity of the animal organism. Suppuration is a treacherous ally, and 
its aid should never be invoked by the modern surgeon, or at least should 
be shunned as long as other ways of curing an ailment remain untried. 



VI. DIAGNOSIS AND TREATMENT OF PHLEGMON. 

1 . General Principles. 

The way to the cure of phlegmonous processes is indicated by the man- 
ner in which unaided nature occasionally accomplishes it. If the direction 
in which suppurative destruction progresses should luckily be outward — 
that is, toward the skin — perforation and spontaneous evacuation of the 
abscess cavity will occur. If by another lucky accident this perforation 
should happen at the time of "maturity," or the comparative repose of the 
destructive process, a complete evacuation' of the deleterious contents will 
take place, followed by a decreasing sero-purulent and bland discharge, and 
by contraction and final occlusion of the cavity. 

But nature unaided is a very poor surgeon. Very often destruction 
does not tend toward the skin ; its natural tendency is to spread in the di- 
rection of least resistance, that is, along the cellular tissue, and, by the time 
that spontaneous openings establish themselves, the damage to deep-seated 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 185 

organs may be very extensive. The coincidence of maturity and perforation 
is also rare. In its absence the perforation will not lead to complete evacua- 
tion, and the septic process will persistently extend in one or another direc- 
tion, not relieved by such incomplete drainage. Lastly, natural drainage by 
perforation will often be located in the most unfavorable place, and will not 
be ample enough for the escape of large masses of pus and of sloughing tissue. 

The most direct indications for the cure of phlegmon are offered by a 
clear understanding of the natural history of its causation and development, 
as presented in the foregoing pages. 

One or more properly made incisions, followed by effective drainage, will 
at once empty the focus of most of its infectious contents, relieving at the 
same time the dangerous amount of tension. 

Infected tissues not yet liquefied, and still adherent to the walls of the 
abscess, must be disinfected by more or less frequent or permanent irriga- 
tion with a germicidal lotion. Finally, all conditions tending to impede 
free arterial and venous circulation must be eliminated by proper position 
— that is, elevation of limbs, removal of constricting dressings or clothing. 

The necessity of rest — that is, the avoidance of all mechanical injury — 
is a matter of course. 

(a) Superficial Suppuration, or Septic Ulcer.— Inspissation of the dis- 
charges of an infected superficial lesion will, by the formation of a crust, 
often prevent proper drainage, causing a more or less complete occlusion 
or retention. The gentlest way of detaching these is by the application of 
a warm dressing of gauze moistened with a two-per-cent solution of carbolic 
acid, evaporation of which should be guarded against by an external layer 
of rubber tissue or oiled silk. After due softening under this warm, moist 
dressing, the overlapping epidermidal masses, hiding small recesses, should 
be laid open by cautiously clipping away their undermined edges with curved 
scissors. This can be done without causing the least pain. Thorough dis- 
infection by the lotion contained in the dressings will thus be possible, and 
the diffusible qualities of carbolic acid will not fail to exert their beneficial 
disinfecting influence upon the germs scattered through the vicinity of the 
ulcer. Its yellow coating, consisting of a superficial layer of mortified tis- 
sues, will be cast off, the angry look of the neighboring skin will disappear, 
and the remaining healthy granulations will soon be cicatrized over. 

Streaks of lymphangitis extending toward the pertinent lymphatic glands 
should be well salved with mercurial ointment. But if their cause — the 
septic state of the ulcer — be removed, they will disappear without special 
treatment. 

(b) Cutaneous and Subcutaneous Phlegmon. — This graver form of sup- 
puration is marked by violent local and general symptoms. High fever, 
with rigors, the general sense of sickness, headache, and a foul tongue and 
breath are present. The skin over the focus of infection becomes deeply 
inflamed, oeclematous, and shows dense infiltration, manifested by hardness 
and pitting. The constant gnawing pain puts sleep out of the question, 
and the spreading of the affection over new areas of tissue is evident. 



186 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



Cataplasm or Incision ? 

The question whether resolution of the gathering by topical applications, 
hot or cold, should be attempted, or immediate incision should be resorted 
to, is of great practical importance, and not always easy to determine. 

The intensity and extent of the process should be herein the main guide. 
The consideration that an incision is after all the most effective antiphlo- 
gistic measure, affording relief from tension, evacuating a very large pro- 
portion of the noxious substances, and permitting the direct application of 
antiseptics — in short, that it promises prompt success, conserves a large part 
of the affected tissues, saves much pain and suffering, and averts local and. 
general danger — should stand foremost in the surgeon's mind, whose per- 
suasive authority ought to gain the patient's consent to an early operation. 
Especially where the rapid spread of the affection and grave general symjo- 
toms make prompt relief urgent, dilatory measures and cowardly tempor- 
izing are improper. The cataplasm is resorted to not only to allay the 
patienfs pain and fear, but often serves as a convenient mantle to hide 
ignorance or indecision. 

Carbuncle represents the most pronounced form of cutaneous phlegmon, 
and its treatment, given hereunder, may, with due modifications, serve as 
a type of the therapy for the entire class of cutaneous suppurations. 

Out of motives of humanity, and because it offers the surgeon time and 
deliberation, so necessary for thorough work, anaesthesia is always advisable, 
— in many cases indispensable. After the usual preparations for an anti- 
septic operation, a free incision should be made through the middle of the 

inflamed area, penetrating through the 
skin to the fascia. One or more small 
foci filled with pus will be thus opened. 
If their number be great, two or three 
more parallel incisions should be added. 
The engorgement or hard infiltration of 
the adjacent skin will be admirably re- 
moved by Volkmann's multiple punctur- 
ing (Fig. 141). The blade of a narrow, 
straight bistoury or tenotomy knife is 
grasped about one third of an inch from 
its point, and is thrust in quick succes- 
sion thirty, forty, or, in very extensive 
cases, a hundred times through different 
parts of the infiltrated region. The 
punctures should be evenly distributed. A large quantity of bloody lymph, 
or occasionally, if a vein be hit, pure blood will escape, and the swelling 
and hardness will at once be markedly reduced. No attempt should be 
made to check this escape of blood or serum, as coagulation will soon stop 
the flow. Thorough irrigation with corrosive-sublimate lotion, packing of 
the deeper incisions with strips of iodoformed gauze, and an ample moist 




Fig. 141. — Attitude of hand far multiple 
puncture. (Volkraann.) 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 187 

dressing, held in place by loose turns of bandage, will complete the work. 
An immediate fall of the temperature, with marked local and general relief, 
will reward both patient and surgeon. Daily, later on, a rarer change of 
dressings will lead to a rapid cure. 

If the patient declines an operation, topical applications are in order. 
Cold, in the shape of iced compresses, or the ice-bag, will be proper where 
the affection is superficial and accompanied by lymphangitis. On the whole, 
it may be said that cold is beneficial in the initial stages of most phlegmon- 
ous affections, and is often very well borne and efficacious in the milder 
forms. To many it becomes unbearable from the time that suppuration 
is well established, and often induces a severe chill, the real cause of which, 
however, is always to be sought in the presence of pus. 

Note. — Cold is badly borne by elderly or run-down subjects, or those prone to 
rheumatism. 

Dry or moist heat is very soothing to many patients, and is a power- 
ful stimulant to the local circulation. Occasionally it undoubtedly averts 
threatening suppuration, and may aptly be employed as a tentative or initi- 
atory measure. However, if the local and general symptoms continue to 
increase, it should not beguile the surgeon into procrastination. Especially 
if a gathering become so massive as to cause fluctuation, incision should not 
be further delayed. 

Xote. — The main effect of the curious and often incomprehensible combinations of sub- 
stances entering, at the recommendation of laymen and some physicians, into the composition of 
poultices, seems to be upon the faith and imagination of the patient. Moist heat is their active 
property, and, the simpler and cleaner its employment, the better it will be. The nauseous prac- 
tice of smearing the skin, or, still worse, a wound, with hot Unseed dough, is not yet extinct. 
Even a well-inclosed poultice is not a proper covering to a wound, unless a clean cloth and clean 
mush be taken for each application. Certainly a mixture of soured linseed with ichor and pus, 
inclosed in a foul rag, is the worst of all abominations that a decaying era of surgery has left 
behind as its legacy. A clean cloth dipped in and wrung out of hot water, covered over with a 
piece of oiled silk, is the best, the cheapest, and the least unappetizing of all cataplasms. The 
cataplasm should never be placed in actual contact with a wound. The interposition of a thin, 
moist dressing will protect the wound from mechanical insults unavoidably connected with the 
change of poultice, and the poultice itself will thus remain unsoiled by the secretions of the 
wound. 

For special treatment of carbuncle, see page 210. 

Subcutaneous phlegmon, left to itself, or treated by too long poul- 
ticing, will assume very large proportions. The form of the abscess cavity 
is rarely globular, but mostly irregular and sinuous. This is partly due to 
confluence of several smaller abscesses, partly to irregular extension, caused 
by the varying density of the subcutaneous connective tissues. Fluctuation 
soon appears, and without delay one or more incisions should be placed so 
as to drain every recess in the most direct manner. Volkmann's punctua- 
tion of the peripherical infiltration of the skin, a thorough irrigation of the 
cavity, and a moist dressing, constitute the treatment of these cases. The 
first incision is made where fluctuation is most marked : the index-finger of 
the left hand is then cautiously inserted, and carefully explores the interior 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of the abscess. This examination is very important, and upon its result 
depends the locating of the drainage-tubes. Counter-incisions are made 
over the tip of the left index, which pushes up the skin from within. All 
squeezing of the abscess at this stage of the operation should be carefully 
avoided. After the placing of the drainage-tubes, and a thorough irriga- 
tion, no pus should be contained in the abscess. If, therefore, gentle 
external pressure causes the escape of new masses of pus, this is a sign that 
one or more recesses, communicating by small openings with the main cavity, 
remain undrained, and need further attention. They must be located, and 
separately incised and drained. 

If fluctuation persist over one or more places in the vicinity of the cen- 
tral abscess, it will be found that unopened, independent abscesses require 

additional incisions. 
Em. i42.-Hiito^Eos^B method of incising a ^he rough tearing and break- 

ing down of septa of tissue with- 
in the abscess by the surgeon's 
finger is unsafe, on account of 
the unnecessary haemorrhage it 
provokes, and because it may 
lead to pulmonary embolism. It 
is better to make a sufficient 
number of counter-incisions. 

The squeezing out of abscess- 
es through an insufficient spon- 
taneous or artificial opening con- 
stitutes what may be called sur- 
gical barbarism. If the opening 
is too small or improperly placed, 
the abscess can never be drained 
by the aid of the law of gravity 
alone. External pressure must 
be employed to remove its con- 
tents, and this must be often 
repeated to prevent refilling of 
the abscess. As " squeezing out " 
is a very painful process, the pa- 
tient will naturally shrink from 
it, and will let matters go. The 
abscess becoming nearly filled, 
only the overflow will escape 
through the insufficient aper- 
ture. The result is slow exten- 
sion of the suppurative process, 
with continuous fever. Dressings of any kind will only make matters worse, 
and no relief will follow till another more properly located artificial or spon- 
taneous opening supply the defect of drainage. 




Fig. 143.— Completed dressing of cervical abscess. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



189 

















IF -#^€&i. 


v ^ ****** 


.. . 







Fig. 144. 



•Underpadding- of safety-pins thrust through drainage- 
tubes after incision of cervical abscess. 



The best proof of the adequate treatment of an abscess is the fact that 
at change of dressings the cavity is found empty, and all the secretions are 
contained in the 
dressings. 

The frequency 
of the change of 
dressings should be 
regulated by the 
amount of the dis- 
charge. 

(c) Deep - seat- 
ed or Subfascial 
Phlegmon. Lymph- 
Gland Abscess. — 
Still more serious 
than subcutaneous 
suppuration is a 
phlegmonous in- 
flammation of the superficial or deep-seated lymphatic glands, or the sub- 
maxillary or the parotid salivary glands. The danger of these forms of 
septic tissue-decomposition consists in the great tension which their pois- 
onous contents attain ; the difficulty of their spontaneous evacuation on 
account of the massive barriers interposed between them and the surface of 
the body, and last, but not least, the likelihood of their perforation into the 
mediastinum, pleura, or peritonaeum, or the erosion of large vessels situated 
in their immediate vicinity. 

Deep-seated phlegmon is characterized by the extremely hard and deep- 
going infiltration of the superjacent tissues, a general and massive oedema 
of the soft parts, extending far beyond the limits of the inflammatory pro- 
cess, so that a limb, for instance, attains double its size ; marked functional 
disability of all organs, even distantly related to the focus of disturbance, 
and very violent symptoms of systemic septic poisoning. 

In the beginning the skin covering the affected locality is cedematous 
but pale ; gradually it flushes up and becomes hard and brawny. 

Incision and drainage is the sovereign therapy in these cases. No time 
should be wasted in attempts at an abortive treatment, as every hour of 
delay may cause irreparable damage. The distant hope of resolution, or 
the desire to produce "maturing" by poulticing, should not be allowed any 
weight in the face of the knowledge that extensive necrosis is the unavoida- 
ble consequence of the rapidly increasing dense infiltration characteristic of 
this condition. Relief from excessive tension is the first and most urgent 
indication, and this can be done only by an incision. 

The objection that these abscesses can not be opened safely while they 
are small, is erroneous, as will be shown directly. But, even if the surgeon 
should not succeed in opening the small cavity, cutting through the integu- 
ment and fascia will do material service by averting the greatest danger. 
26 



190 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Hilton- Roser's method offers a safe and easy manner of evacuating these 
foci. Anaesthesia is, of course, indispensable. A free incision through the 
skin over the most prominent part of the swelling should expose the fascia, 
which should also be divided by easy strokes of the point of the knife to a 
sufficient extent, say an inch or two. After this the knife is laid aside. If 
a small aspirator be at hand, search for pus can be made by puncturing and 
aspirating different parts of the swelling. This, however, is not necessary. 
A grooved director is inserted into the center of the incision, and is briskly 
thrust into the swelling, or, if large vessels be near, is gradually insinuated 
by steady rotating pressure. At a certain point resistance will suddenly 
cease, and a drop of ichor or pus will be seen exuding from the groove of 
the instrument. A dressing-forceps should now be placed in the groove 
of the director, and should be pushed into the focus. The grooved director 
can now be removed, and the forceps withdrawn while its branches are held 
as wide open as possible. A gush of bloody pus will follow the instrument. 
If the opening be too small, dilatation with the dressing-forceps should be 
repeated once or twice, until it becomes large enough to admit a stout drain- 
age-tube. Irrigation and a moist dressing complete the procedure. (Figs. 
142, 143, and 144). 

If the incision was delayed too long, the relief of the general symptoms 
will not be as prompt as after early operations. The presence of adherent 
necrotic tissues explains this fact. But the spread of the mortification is 
checked, and the fever will abate as soon as the sloughs become detached 
and expelled. 

Very numerous applications have taught the author the great value and 
safety of this method, which, therefore, can be warmly recommended. 

Fluctuation is a very late symptom in all deep-seated abscesses, and 
should not be waited for. An explorative aspiration of a doubtful swelling 
will generally disperse uncertainty, and the production of pus will induce 
the patient to consent to the incision. 

The haemorrhage from large, deep-seated abscesses is sometimes copious. 
It comes from the walls of the abscess cavity, which are very vulnerable ; 
hence rough exploration, squeezing, or any unnecessary manipulations 
should be carefully avoided. 

Note. — It is best in cases of great emaciation to open the abscess according to Hilton-Roser 
— to insert a large-sized tube, and to desist altogether from exploration and irrigation until a 
few days later. The cavity will contract, its contents will spontaneously escape toward the point 
of least resistance — that is, through the drainage-tube— to be absorbed by the dressings, and 
much blood will be saved in: this manner. 

Phlegmonous Erysipelas. — A combination of extensive phlegmon with 
true erysipelas is not very common. What is ordinarily known as "phleg- 
monous erysipelas" is generally nothing but a very extensive subcutaneous 
phlegmon, mostly with, sometimes without, subfascial complications. The 
worst cases are directly chargeable to prolonged poulticing, and their treat- 
ment is rendered very difficult by the frequent occlusion of the drainage- 
tubes by large tow-like masses of necrosed connective tissue and fascia. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



191 



Gangrenous phlegmon (Pirogoff's acute purulent oedema) represents one 
of the highest degrees of microbial poisoning, where the multiplication of 
the micro-organisms is 
so rapid and pervad- 
ing that the establish- 
ment of innumerable 
foci throughout all of 
the tissues composing a 
whole limb leads to ex- 
tensive general infiltra- 
tion. Board-like hard- 
ness, a dusky hue of the 




integument, blebs and 







«$*> 



Fig. 146. — Bacilli of malignant oedema in the kidnev 
(700 diameters). (Koch.) 



Fig. 145. — Bacilli of malignant oedema or acute progressive 
phlegmon (700 diameters). (,Koch.) 

ecchymoses, and finally, 

thrombosis of veins and arteries, will end in necrosis of the entire enor- 
mously swollen and cold limb. Incisions do not yield pus, but only give 
vent to scanty quantities of turbid ichorous serum. In these cases the 

prognosis is very bad, and 
the most heroic incisions 
rarely succeed in saving 
the member. If too long 
delayed, even a high am- 
putation may fail to save 
the patient's life. (Figs. 
145 and 146.) 

Emphysematous Gan- 
grene. — The inoculation 
of the human organism 
with a specific bacterium 
(Fig. 134) is generally followed by the development of a dusky, rapidly 
spreading infiltration, exhibiting on palpation the peculiar crackling, and 
on percussion, the tympanitic sound of subcutaneous emphysema. The 
process is accompanied by profound septic intoxication, with delirium, high 
temperatures, chills, and dejection, and terminates in gangrene of the 
affected parts. Eesolute measures — that is, timely amputation performed 
through healthy parts — may succeed in preventing a fatal issue. 

(cl) Acute Infectious Osteomyelitis. — Suppuration of the medullary sub- 
stance of parts of the skeleton represents one of the most dangerous and 
destructive forms of phlegmon. Its cause is the establishment of cult- 
ures of the gold- colored grape-coccus in the capillaries or arterioles of the 
marrow. The manner in which this infection occurs is still matter of 
controversy. So much, however, is known that it is most common during 
adolescence, and that exposure to wet and cold, and certain traumatisms, as, 
for instance, a bruise or severe concussion, are common provocative causes. 
The invasion is marked by a severe chill, followed by a deep alteration 
of the general well-being. Very high temperatures, with chills, somnolency, 



192 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

a dry tongue, foul breath, intense gastric disturbance, bear witness to the 
gravity of the disorder. The insidiousness of the local and the gravity of 
the general symptoms lead to frequent errors of diagnosis on the part of 
practitioners who never have seen this affection, or are careless observers. 
The favorite locality of the disease is the shaft of the long bones near one 
or another epiphysis, as, for instance, the lower end of the femur. This, 
together with the upper part of the shaft of the tibia, is its classical seat. 
No bone, however, is exempt from the disorder. 

The first local manifestation is a deep-seated, unbearable pain, soon fol- 
lowed by a general and deep-going oedema of all the soft parts overlying the 
focus. The skin is pale. As the soft parts covering the adjacent joint are 
also swollen, and its movement is painful, the erroneous diagnosis of acute 
articular rheumatism is frequently made. 

Often the patient is unconscious or quite listless at the time of the phy- 
sician's first visit, and the local symptoms escape attention. As a matter 
of fact, typhoid fever or meningitis is frequently diagnosticated, and the 
affection remains unrecognized until the appearance of a fluctuating swell- 
ing or, in extreme cases, spontaneous perforation of an abscess dispel the 
error. 

The essential features of the morbid process are identical with those of 
cellular phlegmon, modified, however, by the peculiar structure of bone. 
On account of the rigidity of the osseous lamellae inclosing the Haversian 
canals ; of the cancellous and cortical substances inclosing the medullary 
tissue, and of the periosteum, the dense infiltration and massive exudation 
will rapidly heighten the intraosseous tension to such a degree that, the ves- 
sels becoming occluded, more or less extensive necrosis results. 

The excessive tension of the noxious exudations penned up within the 
rigid tissues will cause a copious overflow and absorption of plasm charged 
with ptomaines, which will not fail to cause a profound intoxication, mani- 
fested by very grave general symptoms. 

Cortical osteomyelitis, or what is known in text-books as suppurative 
periostitis, is the mildest form of the affection, and is most amenable to 
preventive treatment. The necrosis caused by it generally involves the 
outer part of the bone only, producing a cortical sequestrum. When the 
epiphysis is attacked in the vicinity of a joint, perforation and articular 
suppuration may occur and very seriously complicate the case. 

Case. — S. C, aged twelve, a somewhat ansemic boy, received, December 19, 1882, 
a kick from a playmate upon the spine of the tibia, which caused considerable pain for 
a while, but no discoloration. The next day a severe chill, with intense local pain 
and an extensive hard swelling of the injured region, set in. The boy became listless 
and delirious ; he rapidly emaciated ; the swelling extended in all directions. The author 
saw the patient December 29, 1882, in consultation with the family attendant, who, 
two days previous to this meeting, had made a small incision corresponding to one of 
the many points where perforation of the skin threatened. The boy being anaesthe- 
tized, a free incision three inches in length was made by gradual preparation down upon 
the anterior surface of the tibia, beginning a little below the patella. Every bleeding 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 193 

vessel was carefully tied at once, and thus clear insight and much bloodsaving were 
effected. A large ulcerative defect of the periosteum was found corresponding to a 
well-circumscribed greenish-yellow spot of the tibia. This defect extended to the cap- 
sule and into the knee-joint, which was found in open communication with the sub- 
periosteal abscess, and was distended with pus. Two incisions were made into the 
joint for purposes of drainage. The popliteal space, thigh, and calf contained a num- 
ber of burrowing secondary abscesses, mostly subcutaneous, which were also severally 
incised and drained. The entire major saphenous veiu was found in a state of puru- 
lent phlebitis, its course being marked by a chain of small, angry-looking swellings of 
the skin, which, on being opened, all yielded pus. As it w T as probable that the entire 
vein would suppurate, it was slit up, beginning from the ankle, to within a few inches 
of Poupart's ligament, and the remaining parts of the thrombus were turned out. The 
hemorrhage from entering branches was checked by packing with narrow strips of 
iodoformed gauze. A very tardy improvement followed these extensive measures. 
January 10, 1883. — A third incision into the upper recess of the knee-joint, and two 
more counter-incisions w T ere made into the popliteal space. Large masses of necrosed 
connective tissue came away at almost each change of dressings, and, although the 
febrile disturbance had much abated, the boy seemed to steadily lose ground on account 
of the enormous suppuration. The cleansing of the wounds was so slow, the pain and 
suffering at the unavoidably frequent change of dressings so distressing and enervating 
to the patient, that, January 14th, amputation was thought of as a last resort. The 
parents, however, firmly declined the step, and fortunately so, as the boy ultimately 
recovered, with anchylosis of the knee-joint. A few small shells of necrosed bone came 
away from the epiphysis previous to the definitive closure of the wound. 

Central osteomyelitis is much more destructive to the osseous tissue than 
the cortical affection, often causing necrosis of the entire shaft. It fre- 
quently extends to the epiphysis, and involves the adjacent joint. 

Note. — The excruciating pain felt by the patient is principally due to the tension of the 
periosteum, separated from the bone by more or less pus. Ordinarily, the extension of suppura- 
tion by perforation into healthy parts is marked by an increase of the local and general suffer- 
ing. Not so in osteomyelitis. Perforation of the periosteum, and evacuation into a loose plane 
of connective tissue, is always marked here by relief of the intense periosteal pain, and often by 
a temporary decline of the fever, due to the reduction of the enormous tension which first pre- 
vailed. With the increase of the tension in the secondary abscess the fever rises again, but the 
pain never reaches its former intensity. 

Similar relations obtain in all forms of suppuration where the seat of the morbid process is 
confined by dense fascia or the capsule of a joint. Submaxillary and parotid cynanche, septic 
inflammations within the prepatellar or olecranic bursas, and all joint-suppurations exhibit the 
same peculiarity. As long as the suppurative process is confined within the mentioned closed 
spaces, the tension and its immediate consequences — necrosis and copious overflow of fever-gen- 
erating poisonous material into the lymphatics, causing intense toxic symptoms — are at their 
acme. As soon as perforation and partial evacuation of incarcerated pus into the meshes of the 
vicinal loose connective tissue occurs, a relaxation of the intense pain and a temporary remis- 
sion of the septic fever are observed. 

Can Necrosis he averted? — Where the diagnosis is made out early, where 
the superficial situation of the bone — for instance, the tibia — favors a precise 
localization of the focus, and where the affection is cortical, a free and early 
incision may avert, and, as a matter of fact, often does avert, necrosis, or at 
least will prevent its extension. In the beginning, perhaps, even the ravages 
of central osteomyelitis could be limited by early trepanning of the medul- 



194 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

lary space in one or more places. So much is certain and proved by experi- 
ence, that prompt incision of the periosteum and trepanning of the affected 
bone admirably relieves the acnity of the local and general symptoms. 

Case. — The author has to quote from memory a very instructive case of recent 
infectious osteomyelitis of the lower end of the humerus observed in 1880 in the surgi- 
cal department of the German Dispensary, and operated in the presence of Dr. W. 
Balser and other colleagues. A young woman, exhibiting an unusual degree of lassi- 
tude and a pitiable facial expression of suffering, was led into the place by two of her 
friends. Her left elbow-joint was semiflexed; it showed a pale, dense, and uniform 
swelling. Her attendants reported that she had had a severe chill in the morning of 
the preceding day, and had been very sick ever since then. The thermometer showed 
105° Fahr. in the axilla. Extremely acute pain was complained of in the lower end 
of the humerus, just above the olecranon. Osteomyelitis being diagnosed, the patient 
was anaesthetized. A good-sized hollow needle being inserted until its point was caught 
by the bone at the site mentioned, a drop or two of thick pus appeared in the barrel 
of the hypodermic syringe. An ample incision was carried along the outside of the 
triceps tendon down to the bone, whereupon about two drachms of pus escaped. The 
periosteum was found detached, and, being deflected by an elevator, was found turgid 
and deep red, except at the place of detachment, where it was broken down and green- 
ish-yellow. Profuse oozing took place from the exposed bone and periosteum, except- 
ing an irregular area of bone covering about two square inches just above the posterior 
supratrochlear fossa. This area was grayish yellow, and did not bleed— in short, was 
necrosed. The wound was loosely packed with carbolized gauze, and was enveloped 
in a moist dressing. The patient was taken to her home, whence she was removed the 
following day to a hospital by her relatives, because she was too sick to be taken care 
of at home. The author was assured that her incessant moaning due to the excruciat- 
ing pain had stopped during the night following the operation. 

Some years ago the author saw a fatal case of pelvic osteomyelitis in consultation 
with Dr. H. Kudlich. The patient succumbed to the violence of the initial symptoms 
— that is, to acute septicaemia. The seat "of the disease was the sacrum and os ilium of 
a very muscular man. Very intense sciatica and high fever composed the initial symp- 
toms. Enormous oedema of the left thigh and inguinal region appeared a short time 
before death, revealing the nature of the affection, which until then had baffled attempts 
at diagnosis. The pelvis was found occupied by phlegmon extending below Poupart's 
ligament. The probable source of the infection was a recrudescent suppurative otitis 
media of old standing. 

The subject is full of difficulty and surrounded by many drawbacks in 
all its aspects. The impossibility of an early and precise diagnosis as to 
location, the depth, and often the inaccessibility of the seat of the disease, 
will render many cases impracticable for preventive treatment. 

Secondary abscesses must be incised and drained as early as possible 
according to rules above given. 

(e) Chronic Suppuration due to Bone Necrosis. Necrotomy. — The most 
common seats of acute osteomyelitis and subsequent bone necrosis are the 
femur and tibia near the knee-joint. 

This fact may perhaps be explained by the circumstance that the upper 
epiphysis of the tibia and the lower epiphysis of the femur ossify much 
later than the other epiphyses of these bones. The active growth and 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



195 




Fig. 147. — Necrotomy of tibia. Leg placed on a hard cushiot 
playing trorn the right. 



Irrigator 



abundant blood-supply near the knee-joint seem to favor the importation 
and deposition there of active micrococci circulating with the blood. 

Next in frequency of be- 
ing attacked is the lower jaw 
near the angle, and the upper 
end of the shaft of the hu- 

Note. — Very likely the different 
arrangement of the nutrient vessels 
of the bones of the upper and lower 
extremities has a certain influence up- 
on the frequency 
of the location of 
osteomyelitis near 
the knee and shoul- 
der joints. The 
nutrient vessels of 
the femur and tibia 
diverge from the 
knee -joint ; those 
of the humerus and 
the bones of the 
forearm converge 
toward the elbow* 
The direct and 
abundant blood-supply of the malleoli and the coxal end of the femur seems to cause an 
earlier consummation of the osteogenetic process at these localities, and also makes them 
liable to a form of infection peculiar to the infantile period of life — namely, tuberculosis. 
Tubercular affections of the ankle- and hip-joints are more common in children than white swell- 
ing of the knee. During adolescence, when the physiological fluxion toward the knee-joint pre- 
ponderates over that toward the ankle and hip, the tendency to osteomyelitis near and tubercu- 
losis near and in the knee-joint becomes more pronounced. Similar relations seem to prevail in 
reference to the upper extremity. During infancy white swelling of the elbow is more common 
than that of the shoulder and wrist-joints; in adolescence the upper end of the humerus is the 
common seat of acute osteomyelitis ; in adults the shoulder and wrist are more frequently 
attacked by tuberculosis and osteomyelitis. 

Whenever an attack of osteomyelitis terminates in the formation of an 
abscess and the establishment of one or more iistulse, the acute features of 
the initial stages of the disorder disappear. The abundant discharge of pus 
is followed for a while by a gradual decrease of secretion, which again in- 
creases as the separation of the sequestrum becomes more and more com- 
plete. This is explained by the fact that, as the dead bone becomes gradu- 
ally detached, the pus-generating surface of the cavity containing the 
sequestrum becomes proportionately larger. In the mean time new osseous 
substance is thrown out by those portions of the adjacent bone and peri- 
osteum which were not destroyed by suppuration, and thus a more or less 
perfect involucrum is formed around the sequestrum. After complete de- 
tachment of the sequestrum, suppuration is generally profuse. 



Hyrtl, "Descriptive Anatomic," 1870, p. 209. 



196 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 148. — Diagram of a transverse section, 
showing relations of sequestrum, involu- 
crum, fistula, and skin. 



If the affection is extensive and no spontaneous or artificial relief is 
vouchsafed for a long period, a deep deterioration of the general health will 

follow, characterized by emaciation, 
anaemia, albuminuria, and in extreme 
cases by amyloid degeneration of the 
liver and kidneys. 

The diagnosis of the presence of 
a sequestrum can be made by noting 
the diffuse thickening of the affected 
bone, the profuse secretion from one 
or more fistulaa, and by direct prob- 
ing. If the direction of the sinuses 
be straight, the silver probe will strike 
bare and roughened bone-surface. The latter symptom, however desirable 
for the establishment of a positive diagnosis, is not absolutely necessary to 
it. Indeed, the cases are quite 
common where tortuous chan- 
nels prevent direct probing. 

Detachment of the seques- 
trum is indicated by its mo- 
bility under the pressure of the 
probe-point, or, when probing 
is impracticable, by the long 
duration of the trouble and 
the increasing or profuse dis- 
charge. 

When to Operate. — It may 
be laid down as a general rule 

that the best time to perform sequestrotomy is after complete detachment 
of the dead bone, which can be ascertained either by probing or by the 
general aspects of the case. Recognition of the necrosed parts and their 

complete removal 
are then easy, and 
will be followed by 
a rapid cure. This 
rule, however, ad- 
mits of important 
exceptions. 

Note. — Extensive 
necroses of the lower 
jaw are frequently ac- 
companied by a profuse 
discharge of fetid pus 
into the oral cavity. 
This and the inability 
to masticate food, do frequently render early relief by operation very desirable. The objection 
that to perform a complete operation will necessitate the sacrifice of healthy bone is not tenable, 




Fig. 149. — Neuber's method. Top of involucrum re- 
moved, skin-flaps turned into the bottom of the 
bone-cavity. 




Fig. 150. — Schede's method. Diagram showing 
izing blood-clot. 



relations of organ- 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 197 

•as it may be urged that even an incomplete operation, if it only accomplish the removal of the 
greatest portion of the sequestrum, will be followed by a decided improvement of the patient's 
condition. After a while, a secondary operation can be done under more favorable circumstances. 
Similar considerations may also indicate an early sequestrotomy in other regions. 

Neckotomy. — Artificial anaemia by Esmarch's band and antisepsis have 
marked important changes in the technique of sequestrotomy. Control of 
the haemorrhage, and the possibility of healing even the largest sequestrot- 
omy wounds without suppuration, justify a deliberate search after detached 
foci containing sequestra by thorough exposure of the interior of the 
affected bones. Long incisions and a free use of mallet and chisel are 
proper. A compressive antiseptic dressing will insure against secondary 
hemorrhage. The formation and maintenance of a moist blood-clot in the 
wound will bring about rapid filling up of the cavity by new-formed bone, 
and will terminate in firm and speedy cicatrization. 

The introduction of the use of Esmarch's band has deprived extensive 
necrotomies of their chief danger — profuse haemorrhage. The danger of 
septic disturbances following necrotomy was slight even before the adoption 
of the antiseptic method, as the densely infiltrated state of the adjoining 
tissues made absorption of septic matter from the wound difficult, and their 
rigidity rendered efficient drainage very easy. The chief advantage of the 
antiseptic method is to be sought in the possibility of effecting a cure with- 
out the long course of suppuration formerly characteristic of the healing of 
these cases. 

Neuber's implantation of skin -flaps was the first step in the direction of 
accelerating the cure of necrotomy wounds. But Schede's methodical and 
successful utilization of the protective properties of the moist blood-clot is 
the simplest and most perfect means to the end in view. 

The indispensable conditions for a successful employment of Schede's 
method are laid down in the following propositions : 

First. Thorough exposure of the seat of the disease by incision and by 
the use of mallet and chisel. 

Secondly. Complete removal of the whole sequestrum, or all the seques- 
tra, and of the entire pyogenic membrane lining the cavities and sinuses, 
by scooping and scraping with the sharp spoon. 

Thirdly. Thorough disinfection of all the nooks and crevices of the 
wound by a vigorous use of the irrigator and corrosive-sublimate lotion, 
and by wiping it out with a clean sponge. 

Note. — The final flushing and mopping out should always be done with the strongest solution 
of corrosive sublimate used by surgeons (1 : 500). Residua of this strong lotion are then washed 
away by a mild solution to prevent mercurial poisoning. 

Fourthly. The formation of a blood-clot which should fill up the wound 
to the level of the skin, and its preservation from putrefaction and exsicca- 
tion by a suitable antiseptic dressing (page 10). 

Note. — -Leaving behind the smallest spiculum of undetected dead bone, or a shred of the 
pyogenic membrane, will partially or totally compromise the success of this procedure, and no 
amount of irrigation will avert suppuration. Fulfillment of the second proposition is not difficult 

27 



198 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

except in the disseminated form of necrosis, where a number of small foci, each containing its 
sequestrum, and all connected by more or less narrow and tortuous channels, are scattered within 
a wide area of the affected bone. But even these difficulties can be overcome by the exercise of 
circumspection, and painstaking favored by artificial anaemia, which renders detection of dis- 
colored bone and the entrance to bone sinuses comparatively easy. 

What Chisels to use. — The chisels generally sold by surgical cutlers have 
little to commend them for efficient and rapid work. Their shape and size 
are unsuitable. "Albert Buck's warranted chisels/' as sold by most hard- 
ware dealers, and generally used by carpenters and joiners, are well tem- 
pered and excellent. They should be fastened to an ordinary, smooth, 
wooden handle, without indentations, to insure the possibility of perfect 
cleansing. The author has found a set consisting of a one-inch, a half- 
inch, and a third-inch chisel, and of a one-inch and a half-inch gouge, to 
answer every purpose. A light wooden mallet, perfectly smooth, its head 
made of boxwood, can be bought in any house-furnishing establishment, and 
is much preferable to the small metal mallets of the instrument-makers. 

The Modern Manner of Performing Necrotomy. — The following descrip- 
tion may serve as an elucidation of the technique of a sequestrotomy. The 
parts being well cleansed with soap and hot water, and disinfected by mercuric 
irrigation, after Esmarch's band is applied, an incision is carried down to 
the bone over or near the fistulse. The length of the external incision 
should be proportionate to the extent of bone thickening. The thickened 
bone should always be attacked where it is most superficial, the site of the 
incision being determined rather by the question of accessibility than by the 
location of the sinuses. Where the bone is superficial, as, for instance, the 
tibia, the incision may be at once carried down to it. Where there is a 
thick mass of overlying soft tissues, the incision should be gradual and pre- 
parative, and all cut vessels should be at once ligatured. The periosteum 
is pried up on both sides of the cut with an elevator, and, where it is found 
adherent by cicatricial tissue, is cut away, until the entire affected area 
is well exposed. Integument and periosteum are held back with a pair of 
Volkmann's retractors, and the roof of the cavity containing the sequestrum 
is chiseled away. This can be done very rapidly by a workmanlike use of 
the mallet and chisel, until the sequestrum is completely exposed. This be- 
ing done, the sequestrum is extracted with a pair of forceps. The irregular 
edges of the cavity are next smoothed off, overhanging parts are removed, 
so as to permit a careful and thorough ocular examination of all its re- 
cesses. Care must be taken not to leave behind any dead bone. The sharp 
spoon should be used in vigorous strokes to clear away all granulations or 
softened osseous tissue, until the entire wound-surface presents a bleeding, 
clean, and healthy appearance. Debris and shrecls of granulations are 
flushed out with a strong irrigating stream, and, to make sure that no de- 
tached particles of tissue are left behind, the cavity should be mopped out 
with a clean sponge. 

Where the operator is not certain of having rendered the cavity perfectly 
aseptic, it is safest not to apply suture, but to fill it with a loose pack- 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



199 



ing of iodofornied gauze, and to swathe the limb in a moist compressive 
dressing. The dressing should be ample, and should contain externally a 
good layer of elastic material, as, for instance, ab- 
sorbent cotton. The turns of the roller bandage 





Fig. 151. 
Carpenters' chisels. 



Fig. 152. 
Boxwood mallet. 



Fig. 153. 
Elevator. 



Fig. 154. 

Volkmann's sharp 

spoon. 



should be tight and close, to insure a sufficient amount of elastic compres- 
sion as a safeguard against secondary haemorrhage. Ample padding will 
prevent strangulation. After the dressing is finished, the limb is held ver- 
tically while Esmarch's band is removed. 

Note. — No alarm need be felt if the finger-tips or toes do not turn pink at once. A 
momentary lowering of the limb will immediately produce the flush indicative of the hyperemia 
due to paresis of the vasomotor nerves. 

Vertical elevation by suspension or propping up should be maintained for 
two or three hours, till a firm clot form in the wound. Should some blood 
permeate the dressings and appear on their surface a short time after the 



200 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



operation, then sufficient pressure was not employed. Suitable-sized com- 
presses of iodoformed and sublimated gauze should at once be laid upon 
the blotch, and should be firmly held down by a clean elastic or flannel 
bandage. This additional pressure by the elastic bandage should not last 
more than an hour. 

Case. — Herman Albertin, school-boy, aged nine. Central sequestrum of lower end 
of shaft of humerus and disseminated necrosis of lower epiphysis due to acute osteomye- 
litis. Necrotomy performed April 12, 1884, at German Hospital, under chloroform. 
A longitudinal incision five inches long, commencing at the upper third of the posterior 
aspect of the left humerus, was successively carried through the skin, fascia, and triceps 
muscle, until the musculo-spiral nerve was exposed and freed from its bed. It was 
taken up and held aside by a blunt hook. The periosteum was incised, turned aside, 
and held up by a pair of Volkmann's four-pronged hooks. The posterior face of the 
thickened shaft of the humerus was chiseled away, exposing an irregular-shaped 
central sequestrum, three inches long. The overlapping parts of the involucrum were 
further chiseled off, until the entire sequestrum could be easily lifted out of its place. 
Two small, round sequestra were removed from the lower epiphysis, and the entire 
trough-shaped cavity was carefully scraped out with a sharp spoon. A small strip of 
iodoformed gauze was placed into the most dependent part of the bone defect, and was 
brought out at the lower angle of the wound. The triceps, fascia, and skin were 
united by three tiers of continuous catgut suture. A compressive gauze dressing was 
bandaged around the limb, and the constricting band was removed. The arm was- 
held in vertical suspension for two hours, and after that was placed in the semi-elevated 
posture on a pillow. The temperature remained normal throughout. The first change 
of dressings was made April 26th, a fortnight after the operation. The dressings con- 
tained only a small quantity of dried blood. The fillet of gauze being removed, a new 
dressing was applied. The patient was discharged from the hospital April 30th, with 
a small, superficially granulating wound corresponding to the place of drainage. He 

returned for another change of dressing May 12th, when 
A B the wound was found entirely cicatrized over. 

In cases where the surgeon is reasonably sure 
of having produced an aseptic wound, either 
Neuber's method of implantation of skin-flaps 
or, what is better, Schede's treatment can be 
employed. 

Neuter's Method of Implantation. — Neuber's 
idea consists in the endeavor to cover up with 
skin, if possible, all the raw surfaces left by the 
operation. Primary union is the object, and a 
minimum of uncovered raw tissues is left to heal 
by granulation. Longitudinal tone defects, such 
as are caused by the removal of a necrosed por- 
tion of the shaft, are partly or entirely covered 
by the turning in of the edges of the cutaneous wound till they meet at or 
near the bottom of the groove in the bone (Fig. 149). It is necessary for 
this purpose to dissect up laterally the skin on both sides of the incision to 
a goodly extent, so as to render it movable and easily held in the new posi- 
tion. One or more wide sutures of catgut are passed through the skin at 




Fig. 155. — Simon Nathan's case 

a, Fenestral defect of tibia 

b, Bridge removed. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



201 



the points of reflection (Fig. 149), to retain the flaps in position ; and, where 
this is not sufficient, a well-disinfected nail is driven through the edge of 
the flap into the hone. The groove thus formed is loosely packed with 
strips of iodoform gauze, and the limb is incased in an aseptic dressing. 

Note. — Nails are disinfected either by boiling in water 
or by being passed through an alcohol -flame till they as- 
sume a dull-red heat. After this they are dropped into 
the vessel holding carbolic lotion and the instruments. 

Ca8e I.— Simon Nathan, clerk, aged nineteen, 
admitted to the German Hospital April 18, 1886. 
Had been operated on three years ago for necrosis 
of tibia by Prof. Schonborn, of Konigsberg. A fist- 
ula remained on the anterior aspect of the leg, that 
closed up and broke open- several times every year. 
The probe detected exposed but smooth bone. April 
22&. — The patient was anaesthetized and the tibia 
was exposed. It was found that the sinus led into an 
oblong defect (Fig. 155) of the shaft, through which 
the probe could be passed, so as to be clearly felt 
beneath the soft tissues of the calf. The length of 
this defect was a little more than an inch, its width 
half an inch, and its walls were formed by very hard 
condensed bone. Apparently the sclerosed condition 
of this bone and its scanty blood-supply was the cause of the frequent ulceration of 
the deciduous granulations forming within the track. The bridge of sclerosed bone, 
together with the adjacent condensed parts of the shaft, were removed by mallet 
and chisel ; the edges of the cutaneous wound were dissected up sufficiently to admit 
of an easy adjustment within the gap between the tibia and fibula (Fig. 156). Two 
stout catgut sutures were passed through both edges of the skin- wound, and were 
brought out by a Peaslee's needle on the under side of the calf, where they were firmly 




Fig. 156.— Simon Nathan's case. 
Implantation of cutaneous edges 
into the defect by transfixing 
catgut suture. 




Fig. 157. — Neuber's method. 



Frank Nagengast's case. Implantation of triangular flap into the 
defect of the head of tibia. 



knotted over a piece of stout drainage-tube. Thus the edges of the skin-flaps were 
well drawn into the bottom of the defect. To somewhat relieve the pressure by the 
drainage-tube upon the skin of the calf, a nail was driven through one of the flaps into 
the tibia, and the leg was dressed antiseptically. Slight elevations of the temperature 
without general or local discomfort were observed on the two successive days, after 
which the normal standard remained unchanged. The dressings were removed May 



202 



EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



9th, and the skin-flaps were found firmly adherent in their new position. Some cutane- 
ous ulceration of the skin on the calf had taken place. The nail was removed. The 
patient was discharged cured June 1st. 

Note. — A sclerosed and ill-nourished state of the involucrura will often lead to a repeated 
breakdown of the granulations lining an old sinus. Stimulating injections will sometimes effect 
a cure, but in rebellious cases success can be had only from a thorough removal of the condensed 
portions of the bone and sinus. 

Case II. — Frank Nagengast, aged eight, a very anaemic boy. Necrotomy of tibia, 
November 2, 1885, at Mount Sinai Hospital. Extraction of a large central sequestrum 




Fig. 158. — Diagram illustrating Schede's method applied to a case like that of Frank Nagengast. 



comprising the entire thickness of the upper half of the shaft, a narrow extension 
reaching down to the lower epiphysis. Three small sequestra, together with a lot of 
softened granular cancellous tissue, were removed from the head of the tibia. The 
remaining posterior portion of the involucrum was so slender and brittle that it broke 

into several fragments during the 
operation. Lateral implantation 
of the skin by means of transfix- 
ing sutures by Peaslee's needle. 
Antiseptic dressing and a lateral 
splint. First change of dressings 
November 23d. Healing of the 
wound by adhesion correspond- 
ing to the shaft. Sinuses lead- 
ing into narrow cavity in lower 
portion of tibia, and a larger 
cavity in the head of the hone. 
Fractures united with some sag- 
ging of tibia downward. De- 
cember 17th. — Bloody rein frac- 
tion of tibia ; scraping of upper 
and lower cavities. January 10, 
1886.— Lower sinus closed; up- 
per cavity shows no tendency to heal. February 22, 1886. — Osteoplastic closure of 
cavity in head of tibia according to Neuber. A triangular skin-flap, containing the 
insertion of the quadriceps tendon and the periosteum, was raised from the anterior 
aspect of the tibia. The remaining roof of the cavity was removed by mallet and 






Fig. 159. — Frank Nagengast' s case, a, Triangular skin- 
nap, b, Skin- flap turned into the cavity ; the dark 
space to heal by granulation, c, View of necrotomy 
wound treated according to Schede's method. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



203 



chisel. Previous to this the capsule of the knee-joint was carefully exposed to avoid 
entering the joint. The granular lining of the cavity was gouged away, and only a 
shell, consisting of the articular surface and the posterior 
portion of the head of the tibia, remained intact. The tri- 
angular skin-flap was turned down into the bottom of this 
cavity, and there attached by a nail (Figs. 157-161). The 
remaining uncovered Y-shaped portion of the wound was 
left to granulate. Under an antiseptic dressing firm union 
of the flap to the underlying bone took place, and the granu- 
lating part of the wound was firmly cicatrized over by the 
middle of April. 

Schede's Method (Fig. 162). — Schede's plan has 
the great advantage over Neuber's method that it 
can be employed successfully under the most vary- 
ing conditions. Its simplicity and independence of 
the presence or absence of a sufficient covering by shin 
commend it to the attention of the surgeon. The 
author found Neuber's plan inadequate where much 
integument had been lost, and was replaced by an 
extensive cicatrix. 




Fig. 160. — Anterior view 
of Frank JNagengast's leg 
after completed cure. 



Case I. — Frank Hyman, aged twelve, received, in May, 
1886, a blow on the left tibia, after which central osteomye- 
litis developed. August 9th. — Necrotomy. Two large se- 
questra were removed from the upper half of the shaft, 

requiring three separate parallel incisions for their extraction. The wound was very 
carefully evacuated of all granulations, and disinfected with a 1 : 1,000 solution of cor- 
rosive sublimate. Simple suture of the cutaneous 
incisions; a small drainage-tube was placed into 
the upper angle of the longest incision. All the 
incisions were covered with strips of disinfected 
rubber tissue, and the limb was dressed with sub- 
limated gauze. The first dressing remained un- 
changed for four weeks, when only a shallow fist- 
ula remained at the place where the drainage-tube 
had lain. This was scraped, and it promptly healed. 

The large cavity became filled with a 
blood-clot, which organized without sup- 
puration. 

The treatment of the osteomyelitic pro- 
cesses of the femur and their sequelae, nota- 
bly of necrosis, presents peculiar difficulties 
of technique mainly due to the deep site of 
the bone. Long incisions are usually indis- 
pensable, access to the remote portions of 
the bone is difficult, and the necessary injury 
to many muscular branches of the femoral artery, and the difficulty of effect- 
ive compression of the muscular masses, render the question of after-haem- 
orrhage rather serious. It is, therefore, advisable not to deplete the limb by 




Fig. 161. — Lateral view of Frank 
Nagengast's leg. 



204 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



an elastic bandage of all its blood before applying Esmarch's constriction. 
Each cut vessel will then pour out a small quantity 
of blood, and can be readily seen and deligated. 
The safest approach to the bone is from the external 
aspect, preferably above, or below the ham-strings. 
On the inner side, Hunter's canal requires careful 
attention on account of the femoral artery. The 
sequestrum is generally located near the posterior 
aspect of the lower end of the shaft. Should it even 
occur that the popliteal abscess perforate on the in- 
ner aspect of the thigh, exposure of the sequestrum 
from the external side will be safer and more easy. 
By the free use of the chisel and mallet, sufficient 
access can be gained to remove the sequestrum. 
Even the most expert operator will occasionally fail 
to find a small sequestrum, or will not succeed in 
its entire removal. The eventual necessity of a repe- 
tition of the operation should be pointed out from 
the outset to the patient. 

Inferior Maxilla. — As a rule, osteomyelitic foci 
of the lower jaw communicate with the oral cavity. 
This makes the preservation of the aseptic condition 
of the wound rather difficult, and sometimes, notably 
in the presence of a neglected and foul set of teeth, 
an impossibility. Where the process is extensive, an 
external incision is preferable, as it lessens the dan- 
ger of the entrance of blood into the respiratory tract, 
and facilitates complete and clean work. 






Fig. 162. — Illustrating successive steps of Schede's dressing, a, Necrotomy wound, b, Protect- 
ive, c, Iodotbrmed gauze. r>, Sublimate gauze, e, Complete dressing. (Case of Samuel 
Krongold. Photographs taken ten days after operation.) 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 205 

Case. — I. Eckert, tailor, aged twenty-three, contracted traumatic acute osteomye- 
litis of the horizontal ramus of the left side of the lower jaw, after the extraction of a 
carious tooth, done November 2, 1886. The intense pain of the beginning was relieved 
by a spontaneous discharge of pus into the oral cavity.' The author saw the patient 
November 23d, when the thickening of the jaw, the profuse secretion, and direct prob- 
ing put the presence of a sequestrum beyond doubt. Sequestrotomy performed Novem- 
ber 25th. The mouth had been prepared for a day or two by frequent rinsings with 
salt water; the face had been shaved. The back of the anaesthetized patient's head 
was rested on a low, hard roll made of a blanket. The hair was wrapped up in a hood 
made of a towel dipped in corrosive sublimate, the chest protected by another wet 
towel. The skin of the jaw was well soaped and rubbed off with mercuric lotion. 
Then an incision two inches and a half in length was made along the lower edge of the 
horizontal ramus. The facial artery was exposed, separated, secured by two pairs of 
artery forceps, cut through between, and doubly deligated. The periosteum was 
incised to the entire length of the external cut, and was reflected upward with an ele- 
vator. Before opening into the oral cavity, a sponge held by a long sponge-holder 
was thrust into the mouth to the vicinity of the fistula, to receive any blood that might 
escape that way. An oblong quadrangle of the external lamella of the alveolar process 
and body of the ramus was chiseled away, exposing a cavity containing three sequestra 
and a mass of ulcerating fetid granulations. The cavity was carefully scraped out by 
the sharp spoon, irrigated with corrosive sublimate, the soiled sponge in the mouth 
having first been substituted by a clean one. The opening freely communicating with 
the oral cavity was plugged with a strip of iodoformed gauze, that reached just within 
the focus ; the external wound was closed by a number of catgut stitches, a short drain- 
age-tube being first placed in its posterior angle. December 2d. — First change of dress- 
ings. No reaction; no fever. External wound was found closed, the drainage-tube 
was shortened, and was found still containing a dark-red blood-clot. The iodoform plug 
was left undisturbed, and was removed by the patient's family attendant at the end of 
the second week. Discharge was scanty throughout. Patient cured December 20th. 

Bone Abscess. — Circumscribed acute osteomyelitis of minor intensity, 
caused very likely by infection with a very limited number of micrococci 
deposited in the medullary substance from the blood, does not have a pro- 
nounced tendency to induce massive necrosis. Breaking down and emul- 
sification of the affected parts are tardy, and thus opportunity is given 
to the surrounding tissues for throwing up around the focus a protective 
wall of granulations. The extension of the abscess is slow, and the local 
as well as general disturbance effected by it is of a chronic character. 
Nightly exacerbations of fever, with occasional chills and sweats, and local- 
ized, deep-seated pain of a throbbing nature, gradual hypertrophy of the 
bone, with atrophy of the pertinent muscles, trophic changes of the skin, 
as glossiness and local sweats, and increasing emaciation, are the character- 
istic symptoms of the affection, which extends over months and even years. 
The marked thickening of the bone, the spontaneous local pain, augmented 
by pressure on percussion, and the absence of fistula are mainly to be con- 
sidered as to diagnosis. Therapy consists in doing what is to be done with 
all abscesses — evacuation and eventually drainage. 

The conspicuous thickening of the bone serves as a convenient guide to 
the purulent focus. After the application of Esmarch's constrictor, a free 
28 



206 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



incision, made according to the rules described in the paragraph on necroto- 
my, exposes the bone, the surface of which is generally found covered with 
osteophytic excrescences, that somewhat impede the raising up of the peri- 
osteum. All the soft parts being held away by sharp retractors, the thick 
layer of new-formed bone is pared oh* with the chisel, layer by layer, until 
the cavity containing pas is exposed. Sometimes a number of discrete or 
communicating foci are present, and the surgeon must make sure of not 
overlooking any of them. It is best, accordingly, to expose the medullary 
space throughout the entire extent of the thickening. By entirely removing 
the roof of the cavity, it is converted, into a more or less shallow trough, 
all parts of which are exposed to ocular inspection. The smooth pyogenic 
membrane lining the abscess is carefully removed to its last shred by vigor- 
ous scraping and gouging with the sharp spoon, and by subsequent irriga- 
tion. A final flushing of the wound with a strong (1 : 500) solution of 
corrosive sublimate will make sure of the destruction of all lingering germs. 
The wound is sutured and dressed according to Schede's plan, and, if the 
removal of all diseased tissues and infectious secretions was thorough, rapid 
and uninterrupted healing under the blood-clot will take place. 

Case I. — Richard Boss, metal-worker, aged thirty-eight. Chronic painful thick- 
ening of the shaft of the humerus of two years' standing. Glossy skin, atrophy of the 
muscles of the arm and forearm, formication, and hyperidrosis, together with paretic 
symptoms affecting 
principally the mus- 
culo - spiral nerve. 
Nightly exacerba- 
tions of local pain 
and hectic emacia- 
tion. February 2, 
1887.— At the Ger- 
man Hospital, expos- 
ure by chisel and 
mallet of a bone ab- 




Elasti 



mstrictor 



Fig. 163. — Exposure of thickened humerus containing a central bone absces 

tied above the acromion, and thence passed around thorax into the opposite armpit, where 
it is secured by another ligature. 



scess occupying the middle and upper part of the medullary cavity of the left hume- 
rus. Schede's method of dressing the wound. February 17th.— First change of dress- 
ings. Wound united by the first intention. Two superficial drainage-tubes were 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 



207 



removed. March 6 th. — 
Patient discharged per- 
fectly cured with im- 
proving function of the 
extremity. (Figs. 163, 
164, and 165.) 

Case II. — Samuel 
Krongold, school - boy, 
aged twelve, had had, 
several years ago, com- 
pound dislocation and 
acute suppuration of the 
left elbow-joint, compli- 
cated with acute osteo- 
myelitis of the lower 
epiphysis of the hume- 
rus, in consequence of 
which several sequestra 
had to be removed by the 
author. Three months 
ago a painful thickening 
of the shaft of the hu- 
merus appeared, causing 
marked deterioration of 
the boy's health. February 1&, 1887. — At the German Hospital, a central bone abscess 
occupying the middle portion of the medullary space of the humerus was exposed and 
evacuated, and was treated by Schede's method. February 26th. — The first change of 
dressings took place, and the entire wound was found healed with the exception of 
the slit left open for drainage at the lower angle of the wound, which was occluded by a 




-Cavity chiseled 

* sharp spoon 



ts contents r< 
(Richard Boss.) 




fresh - looking blood - clot. 
March 6th. — Patient dis- 
charged completely cured. 
(Fig. 162.) 

The remarkably short 
and complete cure of 
both of these cases is 
undoubtedly to be at- 
tributed to the adoption of Schede's plan. Plugging of and introducing 
drainage-tubes or any foreign substance into the bone cavity are done away 



Fig. 165. — Richard Boss's wound treated according to 
Schede's method. Photograph taken February 17th, 
fifteen days after operation. 



208 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

with, and organization of the massive blood-clot goes on uninterruptedly 
to the greatest advantage. 

Conclusions. 

Prevention of infection contains the spirit and aim of aseptic surgery ; 
the object of antiseptic surgery is disinfection and the conservation of 
infected tissues. The first object is attained by a severe discipline of clean- 
liness ; the second by the still more severe discipline of early incisions and 
adequate drainage and disinfection. 

A clear comprehension of the processes determining suppuration must 
result in the firm conviction that an early and free incision of every focus 
of septic inflammation is the most conservative form of treatment. It pre- 
vents local death and general intoxication, the latter only too often the 
cause of general death. If this conviction will have entered into the " suc- 
cum et sanguinem " of every physician, public opinion will gradually yield 
to a better understanding of individual and the public interest. 

Note. — The change in the surgeon's attitude toward the employment of incisions for septic 
inflammative processes is characterized by these sentences : 

Formerly, topical applications were the main reliance, incision only a last and extreme 
resort. The surgeon had to show cause why an incision should be made. 

At present, relief from tension and escape of the noxious substances through incision and 
drainage is the clear indication to be fulfilled. The surgeon must shoiv cause why an incision 
should not be made in the presence of septic inflammation. 

2. Phlegmonous Affections of some Special Regions. 
a. Face. Floor of the Mouth. Neck. Temporal and Mastoid Regions : 

Anatomical Arrangement of the Connective- Tissue Planes of the Neck. — Ilenke's 
classical essay is the best guide for the clear comprehension of this subject. He injected 
the different interspaces of a cadaver with liquid gelatin, and studied the manner of 
its extension between the several organs by exposing the congealed masses, and examin- 
ing their relations in situ. The chief interspaces of the neck are classified by Henke 
as follows : 

1. The Capsule of the Submaxillary Salivary Gland — It forms a completely closed 
envelope to the gland, from which continuations extend to the superficial and deep 
cervical fasciae. 

2. " Previsceral Interspace.' 1 '' — The connective-tissue plane or interspace situated 
between the prelaryngeal group of longitudinal muscles (hyo-thyroids, sterno-hyoids, 
and sterno-thyroids) anteriorly, and the larynx, thyroid gland, and trachea posteriorly. 
It communicates with the anterior mediastinum. Perforation of a suppurating thyroid 
gland leads to invasion of this space, with subsequent compression of the trachea. 
(Fig. 166, c.) 

Case. — S. C, aged seventeen. The patient was treated by Dr. C. Lellmann for typhoid fever 
in the German Hospital. In the third week of the disease severe dyspncea developed, with a 
peculiar wheezing sound accompanying respiration. On examination, a diffuse swelling was 
noted in front of the neck. Incision evacuated an abscess communicating with the interior of 
the thyroid gland, whence perforation must have taken place. Immediate relief followed. 

3. " Retrovisceral Interspace.'''' — The interspace between the pharynx and oesoph- 
agus in front, and the vertebral column behind. It communicates with the posterior 
mediastinum. (Fig. 166, a.) 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 



209 



STERNOHYOID 



YROID GLAND 



4. '•'■Perivascular Interspace." — The interspace containing the carotid artery and 
jugular vein. It communicates with the anterior mediastinum along the course of the 
large vessels, and is important on account of the frequent suppuration of the group of 
lymphatic glands sit- 
uated in front of, 
and externally to 
the jugular vein. 
Abscesses of this in- 
terspace displace the 
sterno-mastoid mus- 
cle outward; they 
extend along the 
vessels downward, 
and, left to them- 
selves, either per- 
forate through the 
deep and the super- 
ficial fasciae and the 
skin near the clavi- 
cle, between the low- 
er end of the sterno- 
mastoid muscle and 
the trachea, or make 
their way along the 
vessels into the an- 
terior mediastinum. 
(Fig. 167.) 

5. "-Intermuscu- 
lar Space." — An interspace situated at their crossing, between the lower third of the 
sterno-mastoid and the omo-hyoid muscles. This space owes its origin to the sliding 

of these contiguous mus- 
cles upon each other, and 
is limited posteriorly by 
the scaleni. It contains a 
group of lymphatic glands, 
seated near the posterior 
edge of the lower third of 
the sterno-mastoid muscle 
(supraclavicular glands), 
and communicates inward 
and upward with the 
retrovisceral space, and 
along the subclavian ves- 
sels with the axillary cav- 
ity. Supraclavicular ab- 
scesses usually extend into 
the arm-pit. (Fig. 168.) 




Fig. 



166. — c, Previsceral space. 
Antero-posterior section. 



l, Eetrovisceral interspace. 
(From Henke.) 



omoh yo i d 
sternothyroid\ sternohyoid 

subcutanian 



CAROTID 

JUGULAR 




SPLENIUS 



TRAPEZIUS 

Fig. 167. — Perivascular interspace. 
(From Henke. J 



Transverse section. 



(a) Face. — The 
most serious form of 
cutaneous and subcu- 



210 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 168. — Intermuscular space. Lateral antero-posterior section. 
(From Henke.) 



tan eons phlegmon observed on the face is the carbtmcle. It is characterized 
by a dense, hard swelling of conical shape, extending far into the subcu- 
taneous connective tis- 
sue. It has a dusky 
red color, and its apex 
is marked by one or 
more yellowish discol- 
ored spots, which are 
surrounded by a bluish 
halo. Septic thrombo- 
sis extending through 
the jugular veins into 
the cranium is to be 
feared in this affec- 
tion. The systemic in- 
toxication is generally 
very intense, high fe- 
ver being the rule. In 
some of the worst cases the intoxication is so deep as to cause symptoms of 
collapse, w T ith low, sometimes even subnormal, temperatures. 

In this condition an early and most energetic treatment is urgently 
indicated, and is almost always followed by elimination of the infectious 
process. 

A crucial incision, or, in extensive cases, a number of parallel incisions, 
carried in length and depth beyond the indurated area, will relieve tension 
and permit the escape of the contents of many smaller or larger incarcerated 
foci. The incisions should be packed lightly with strips of iodoformed 
gauze. In cases of anaemia, where loss of blood would materially increase 
the danger, the actual cautery should be so applied as to convert the entire 
infected area into a dry eschar. This or the incisions should be enveloped 
in a moist dressing, which has to be renewed according to the amount of 
secretions. 

Note. — The following bloodless treatment applied by Slesarewskij in forty-four cases of car- 
buncle seems to deserve trial, as it yielded very good results in his hands : Inspissated crusts are 
first removed, then the diseased surface is sprinkled with from thirty to sixty grains of corrosive- 
sublimate powder. The dusky halo surrounding the center of the sore is thickly covered with 
blue ointment, and the whole is enveloped in a compress soaked in carbolized oil (1 : 10), fast- 
ened with a roller bandage. In case of severe pain, an ice-bag is placed over the dressing. The 
following day, corresponding to the application of the mercuric salt, a gray, very dense eschar 
will be visible, which will separate ten days later, and will be followed by rapid healing. 
Slesarewskij never observed mercuric intoxication during or after the application of this method 
of treatment. (" Centralblatt fur Chimrgie," 1886, p. 805.) 

Case. — The author lost, of a considerable number of cases treated by incision, only 
one by septic phlebitis of the right lateral sinus. The patient, a middle-aged cigar- 
maker, was seen in consultation with Dr. L. Weiss, and an enormous carbuncle occupy- 
ing the right side of the upper lip and cheek was found, with extensive oedema of the 
eyelids and the right side of face and neck, which was due to general thrombosis of 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



211 



the pertinent veins. The patient was semi-comatose, somewhat cyanosed, and had a 
poor pulse. He had obstinately opposed any incisive treatment for six days, and the 
case seemed clearly beyond the reach of surgical skill. The incisions caused very little 
haemorrhage, as most of the divided tissues were necrosed. He died of collapse on the 
seventh day of his illness. 

The author has never tried any of the "maturing"- forms of treatment 
in this affection, and would unhesitatingly declare measures which are apt 
to stimulate suppuration, such as poulticing, to be always risky, and some- 
times positively dangerous. 

(b) Neck. — (a) Fauces and Pharynx. — The tonsils and the connective 
tissue in which they lie imbedded are the most favorite site of superficial 
and deep-seated septic processes. Diphtheria is very likely a microbial 
affection due to the colonization of micrococci upon the surface and in the 
follicles of tonsils, that are in a state of catarrhal or scarlatinal inflammation. 
It is characterized by superficial or deep-going putrid necrosis of the affected 
tissues, often extending to the pharynx, larynx, velum, pillars, and the nasal 
mucous membrane, and is generally accompanied by a serious general intoxi- 
cation. The systemic intoxication is most prominent when parts having 
an abundant supply of lymphatics, as the pillars of the fauces, the velum, 
pharynx, and nasal mucous membrane, are involved. The scantier de- 
velopment of the tonsillar 







\ 






IK 



iSe 



#+ 



and laryngeal lymph -ves- 
sels seems to be the cause 
of the minor intensity of 
the systemic symptoms ob- 
served in affections local- 
ized in these parts. Char- 
acteristic intumescence of 
the deep cervical lymph- 
glands is a regular conse- 
quence of the affection of 
the first group of localities; it is 
more rarely observed in purely 
tonsillar or laryngeal diphtheria. 
An invasion is apt to leave be- 
hind a certain disposition to re- 
newed attacks, which is due to 
the fact that quiescent spores of bacteria remain imbedded in the recesses 
of the follicles, to develop anew their activity whenever a new catarrhal 
inflammation and exudative process prepares the ground for their multi- 
plication. 

But, on the other hand, frequent attacks, and the accompanying 
formation of cicatricial tissue within the textures of the tonsils, seem 
to lead to a certain immunity from the graver forms of the disease. As 
a rule, persons who never had diphtheria suffer more severely than those 
who have gone through many attacks ; and diphtheria of children for- 






Fig. 169. — Bacteria from case of vesical diphtheria 
with putrescence (700 diameters). (Koch.) 



212 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

merly free from the disease is a much more serious condition than the 
so-called habitual " follicular tonsillitis." While a first attack is usu- 
ally, habitual follicular tonsillitis is rarely, complicated with glandular 
enlargement. 

The condition of things here is comparable to that which was mentioned 
as the "habituation of the hands of anatomists to septic infection" (see 
page 183, Note I). The disease is highly contagious, hence isolation of the 
patient is imperative wherever possible. 

Aided by a sustaining and stimulating general treatment, the disinfec- 
tion of the local septic state should be most energetically pursued. Accord- 
ing to the age and disposition of the patient, this will have to be done dif- 
ferently. In small children of a good disposition, pencilings of the affected 
parts with milder or stronger solutions of corrosive sublimate repeated every 
hour, and, in case of nasal diphtheria, hourly syringing of the interior of 
the nose, should be practiced. A mixture of corrosive sublimate 0*03, 
alcohol 25*00 (or one-half grain to the ounce), can be safely used for pencil- 
ing the tonsils and pharynx. A tepid watery solution of 1: 5,000 for syring- 
ing the nasal cavity will be well borne. Care must be taken to keep the 
nostrils well anointed with vaseline to prevent eczema, and never to use a 
sharp, long-beaked syringe. During the struggles of the resisting child the 
mucous membrane is easily lacerated, and the haemorrhage and certain infec- 
tion of the part thus injured are not indifferent in an affection where the 
least complication may suffice to fatally determine the case. The safest 
manner of douching the nose is by attaching to the nozzle of the syringe 
a piece (six inches in length) of soft rubber tubing, such as is used on 
infants' feeding-bottles, its distal end being first provided with a few lat- 
eral holes cut into it with scissors. The syringe is filled with the warm 
lotion, the well-greased flexible tube is introduced into the nostril and 
pushed back until it is felt to touch the posterior pharyngeal wall, the 
child's head is inclined forward, and then the contents of the syringe are 
briskly thrown into the nasal cavity. The immediate reflex closure of 
the larynx and isthmus faucium will prevent the entrance of considerable 
quantities of the lotion into these organs, and the energetic stream will 
aid or result in the detachment and expulsion of crusts, membrane, and 
liquid secretions. On account of the swollen condition' of the mucous 
membrane, the entrance of acrid secretions into the Eustachian tubes need 
not be feared. 

The throats of larger children or grown persons can be cleansed by fre- 
quent gargling with a tepid solution of (1 : 5,000) corrosive sublimate, con- 
taining one teaspoonful of cooking salt. The principal weight should be 
laid upon a frequent application of the gargle and a stimulating, nourish- 
ing, general regime. 

Whenever the aspect of the malady is very threatening, the application 
of the actual cautery to the affected parts is advisable. It is, aside from 
the necessity of a short anaesthesia, an entirely safe and rational process. 
That only a portion of the patches are accessible, some of them being 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 



213 



beyond the surgeon's reach in the nasal cavity, is no valid reason why 
those that are amenable to this vary effective mode of disinfection, should 
not thus be treated. 

The best way of cauterizing the tonsils and pharynx is the following 
one : 

The head of the anaesthetized patient is drawn over the unclerpadded 
edge of the table until it assumes the dependent, or Rose's, position (Fig. 
170). The surgeon introduces a bent tongue-depressor, or the bent handle 
of a tablespoon, well back into the fauces, and instructs the anaesthe- 
tizer to keep the tongue out of the 
way by it. This will expose the 
pharynx in an admirable fashion to 
permit of the exact and thorough ap- 
plication of the thermo- or galvano- 
cautery to the patches thus exposed. 
If the disease be limited to visible 
parts of the oral cavity, and all the 
patches can be thus treated, a rapid 
improvement of the general state of 
intoxication will, as a rule, at once 
follow the procedure. Where only a 
part of the patches is thus treated, the 
improvement will not be as complete. 

The glandular enlargement also 
requires attention, and should be 
treated as was explained elsewhere. 

If the process descend to the larynx, very alarming dyspnoea will grad- 
ually develop. It should be combated with external hot applications to the 
throat, and the inhalation of moist, warm air generated in the sick-room. 
The patient's strength should be carefully husbanded by frequent doses of 
liquid nourishment, and the avoidance of unnecessary excitement, exposure, 
and, most of all, strong emetics, the abuse of which has cost many a child's 
life. In most cases the membrane will get detached piecemeal, or will 
come away in one or more large masses, and relief will follow, perhaps only 
to be succeeded by another or several suffocative attacks. As long as there is 
no lung complication, the pulse fairly good, intubation offers fair chances of 
success. Where the patient's strength has been consumed by a very long, 
ceaseless struggle for air, or the depressing use of emetics, the chances are 
by far more slender. Yet even the most desperate cases sometimes yield 
unexpectedly good results. "When intubation is not feasible, tracheotomy 
has to be performed. 

Preventive Treatment of Tonsillitis. — The tonsils are the points where 
the first patches become visible in most cases, and whence the local infec- 
tion extends to other contiguous parts. After frequent attacks of tonsillitis, 
the surface of the tonsils becomes irregularly indented by cicatricial retrac- 
tion ; the tonsil itself is enlarged, and often yields on pressure one or more 
29 




Fig. 170. — Rose's position. Head dependent 
from the edge of the operating table. 



214 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

yellowish plugs of a yery fetid cheesy matter which were contained within 
the follicles. 

Note. — Drs. E. Gruening and S. Cohn called my attention to this fact, which I have repeat- 
edly verified. 

These yellowish masses are, as shown by Gruening, swarming with lep- 
tothrix and other micro-organisms, and the presence of these is undoubt- 
edly at the bottom of the so-called " disposition " to catch the disease. The 
reservoir of infecting material is ever there ; the patient carries it constantly 
with him, and a catarrhal hyperemia, followed by some infiltration and 
epithelial erosion, is all that is needed to develop a new attack of " follic- 
ular tonsillitis," which may not threaten its possessor with great danger, 
but is just as contagious to others as any case of diphtheria. One observa- 
tion like the following will carry much conviction. 

Two children of the same family had attacks of sore throat one after the other. 
The first, a boy four years old, who has had tonsillitis a number of times, exhibited the 
usual symptoms of his affection ; the second one, a boy about a year old, and hitherto 
free from the disease, was carried into the sick-room of the first child by an obstinate 
nurse, and came down the next day with very alarming systemic symptoms, high fever, 
and somnolence, exhibiting a small patch on his left tonsil. The first boy recovered in 
about four days, the usual length of his attack ; by the time that be was well, the baby 
had died under symptoms of most acute septicemia. A petechial rash, commencing 
on the nates and feet, extended upward, and gradually flecked the entire skin. The 
patch on the tonsil had grown and others had developed, the somnolence turned into 
coma, and was followed by death. 

The wet-nnrse of this child and the cook of the family, who had kissed the corpse, 
became seriously ill with diphtheria ; especially the latter, whose condition was critical 
for three or four days. At the same time, a male servant and two more members of 
the family contracted sore throats of various degrees of intensity, and the house had 
to be abandoned. A friend and his wife called in the evening shortly after the child's 
death to pay a visit of condolence. The next morning one of their children was down 
with malignant diphtheria, and died in a day or two of septicaemia. 

Destroying the entire surface of the tonsil, together with the contents of 
the follicles by the application of the actual cautery, would seem to be 
rational, and has been found a safe and effective measure for lessening the 
disposition to renewed attacks of diphtheria. It is infinitely safer than a 
bloody ablation of the tonsils, as the dangers of haemorrhage and diphtheria 
of the wound-surface are thereby avoided. The smooth, dense cicatrix thus 
produced offers a very good protection against new infection. 

In adults, or even in half-grown children amenable to control, the reduc- 
tion of the tonsil can be gradually accomplished without general anaesthe- 
sia, the procedure extending over a number of sittings. The throat is pen- 
cilled with a cocaine solution until local anaesthesia is produced ; then a cold 
galvano-canstic burner is introduced. It is placed against the part to be 
treated, the current is turned on, and one fourth or one third of the ton- 
sillar surface is thoroughly seared. For an hour or so, small pieces of ice 
should be swallowed by the patient to allay the slight pain. The sittings 
can be repeated about twice a week or oftener. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 215 

Quincy sore throat (peritonsillitis) is a phlegmonous process established 
in the tonsil itself, or in the loose connective tissue in which it is imbedded. 
The tonsil is found enlarged, projecting into the pharynx, and displacing 
forward the anterior pillar and velum. Dysphagia and more or less saliva- 
tion with high fever are regularly present, and do not terminate until 
thorough evacuation has taken place. In most cases confluence of a number 
of small abscesses and simultaneous evacuation is observed. In others, 
especially when the tonsil itself is the seat of the affection, a number of 
abscesses develop and open one after another, and retard recovery for a 
week or two. No local treatment short of incision can effect a substantial 
improvement, and the different gargling mixtures are only useful in clear- 
ing the throat and mouth of the foul, sticky slime aggravating the patient's 
sufferings by exciting very painful reflex movements at deglutition. Hot 
salt water (one teaspoonful to a quart, about 6 : 1,000) is the best, as it is 
the most solvent gargle, and can be easily procured. As the exact location 
of the abscess can not be ascertained easily beforehand, it is wise to wait 
with the incision until the swelling is well developed. A digital examina- 
tion of the swollen region is always advisable, as it is not rare that the tip 
of the finger detects a pitting spot at which incision will release pus. If 
pitting can not be detected, an examination with the tip of a silver probe 
will possibly help to ascertain the most painful spot corresponding to the 
focus to be incised. The relative distribution of the swelling may also serve 
as a guide in determining the seat of pus. Acute enlargement of the tonsil 
itself with diffuse oedema of the pillars and palate indicates suppuration 
within the tonsil. Displacement of the relatively normal tonsil inward is a 
sign of retro-tonsillar suppuration. A combination of both will show the 
worst association of distressing symptoms. 

Incising Tonsillar Abscess. — A lancet-shaped pointed bistoury is pro- 
tected with strips of adhesive plaster to within an inch of its point (Fig. 
171), the tongue is depressed with the left index-finger, while the right 
hand thrusts the knife into the base of the swelling through the anterior 
pillar at the point 
previously deter- 
mined. The an- 
teroposterior di- 
rection should be Fig. 1^- — lancet-shaped bistoury wrapped up in adhesive plaster for 
. . incision of tonsillar abscess. 

rigidly adhered to 

on account of the vicinity of the carotid artery. If the first puncture be 
unsuccessful, a second one should be made in another likely place, and, as 
soon as pus appears, the blade should be turned inward, that is, toward the 
median line, and should be withdrawn, dilating the incision in that direc- 
tion. A number of fibers belonging to the levator palati will be thus divided, 
and their retraction will create a patent orifice, favorable to good drainage. 
Retro-pharyngeal phlegmon is a comparatively rare suppuration of the 
retro-pharyngeal connective tissue, due to septic infection of the glands 
normally imbedded in it. It is mostly observed in small children. The 




216 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

symptoms are those of retro-pharyngeal abscess from tuberculous caries of 
the cervical vertebrae, but its appearance is much more rapid, accompanied 
by high septic fever and more acute local distress, causing difficulty of 
deglutition, regurgitation of food through the nostrils, and alarming 
dyspnoea. The most characteristic symptom is the peculiarly rigid attitude 
of the head, which is erect and thrown back to a certain extent at the same 
time. The voice is thick and guttural, as though a voluminous foreign 
body were held in the throat. 

In some cases the suppuration extends to the "intermuscular space," 
and causes the appearance of a lateral external swelling behind the sterno- 
mastoid muscle. The transverse diameter of the neck then appears widened. 
Inspection of the pharynx shows that the posterior pharyngeal wall is dis- 
placed forward, is densely infiltrated, and sometimes fluctuating. 

Incision should be done through the oral cavity if the inflammation is 
confined to the retro-pharyngeal region, but will be more advantageous if 
done from without and behind the sterno-mastoid muscle in cases where 
external swelling of the cervical region is noticeable. 

In the first case, the children should be held as for penciling of the 
throat, and the person having charge of the head should be instructed to 
throw it forward at a given signal, so as to favor the escape of pus and 
blood outward from the oral cavity, and prevent its entering the larynx. 

If lateral swellings appear, proper incision from without will afford 
efficient drainage, and at the same time will help to avoid the dangers accru- 
ing from the entrance of pus into the larynx. 

The manner of incision is best illustrated by the subjoined cases. 

Of a large number of cases treated at the German Dispensary, and a few 
seen at consultations in private practice, only two have terminated fatally, 
and in both serious haemorrhage occurred a few hours after the incision. 

Case I. — S. P., aged eighteen months, seen May 17, 1883, with Dr. L. Weiss. 
Retro-pharyngeal and submaxillary abscess developed during the florid stage of a 
violent scarlatina with diphtheria. Dysphagia and dyspnoea. Small lateral incision 
through the skin and fascia parallel to, and behind the posterior margin of the left 
sterno-mastoid muscle. Successful search for pus with a stout hypodermic needle, carried 
inward and a little backward toward the retro-pharyngeal space. Insinuation of a 
grooved director along the hollow needle, followed up by the introduction of a small 
pair of dressing forceps, which were withdrawn half opened. Escape of about one 
and a half ounce of pus and introduction of a drainage-tube. Two hours after incision 
copious secondary haemorrhage set in, and rapidly terminated in death. Giving away 
of the wall of a sloughing vessel must be assumed to have caused this issue. 

Case II. — Henry W., aged four and a half months, a healthy child, developed, 
March 4, 1883, fever and dysphagia, due to the presence of a number of small abscesses 
situated in the retro-pharyngeal connective tissue. Several of these were incised by 
Dr. A. Jacobi, with apparent relief of short duration. New foci appearing, the incisions 
were repeated March 6th and 8th. March 9th. — Dysphagia became complete and 
dyspnoea alarming. Although the incisions through the retro-pharyngeal space con- 
tinued to bleed, increasing the danger by the addition of haemorrhage to the other 
symptoms, the extension of the process to the connective-tissue plane of the large 



DIx\GNOSIS AND TREATMENT OF PHLEGMON. 217 

vessels and the alarming dyspnoea left no alternative but death from suffocation or an 
incision of the abscess from without. March 9th, at 2 P. M. — This was done, evacuat- 
ing about half an ounce of pus. A drainage-tube was introduced into the bottom of the 
cavity, and, to limit the oozing, a compressory dressing was applied. At J/, P. M. — 
Scanty but continuous haemorrhage set in from the drainage-tube. This being removed, 
the cavity was plugged with strips of iodoformed gauze, and the bleeding edges of the 
incision were seared with the thermo-cautery. At 8.30 P. M. — The child died of acute 
anaemia. 

March 10th. — Post-mortem examination by Dr. A. Seibert in the presence of Dr. 
L. Bopp and the author. On the neck, close to the posterior edge of the left sterno- 
mastoid, a cutaneous incision was found one inch in length, its edges marked by a 
dark-red, bloody infiltration. A probe entered the retro-pharyngeal space, where it 
could be felt with the finger placed in the oral cavity. A skin-flap being raised and 
turned upward, a couple of intumescent, dark-red lymph-glands, situated near the an- 
terior edge of the sterno -mastoid muscle, were exposed. The sterno-mastoid muscle 
was cut away at its lower insertion and was turned upward. The vascular sheath was 
opened, and the deep jugular vein and carotid artery were carefully examined and 
found intact. A wall of tissue one third of an inch in thickness was found interposed 
between these vessels and the track occupied by the silver probe. The prevertebral 
interspace was found distended by a dark, massive, and soft clot, extending upward to 
the base of the cranium, and downward to the level o| the third tracheal cartilage. 
Cervical vertebrae normal. 

Doubtless it was a case of haemophilism. 

(A case of retro-pharyngeal infiltration, simulating the symptoms of abscess, was 
seen by the author in the German Hospital, in which acute infectious osteomyelitis 
of the second cervical vertebra was the cause of the trouble. Henry Lud wig, bartender, 
aged twenty-one. February 16, 1885. — High fever set in with a chill and stertorous 
breathing. The face was slightly cyanosed and the voice had a thick sound character- 
istic of retro-phavyngeal swelling. The patient held his neck rigidly, and in moving 
supported it by his hands. A typhoid condition prevailed. The house surgeon of the 
German Hospital made a free incision into the swelling occupying the retro-pharyngeal 
region, but no pus escaped. In spite of weight extension, sudden death occurred, March 
20th, from compression of the medulla. Post-mortem examination revealed a far-gone 
destruction of the second, third, and fourth cervical vertebrae. The odontoid process 
was detached, and had fatally compressed the medulla.) 

Acute infectious osteomyelitis of the lower jaw occurs either in the adult 
after traumatism, such as for instance fracture of its entire thickness by 
violence, or injury to the alveolar process caused by the extraction of teeth ; 
or spontaneously in the adolescent. The latter form is quite frequent, and 
results generally in more or less extensive necrosis and the formation of 
abscess. Perforation usually takes place toward the oral cavity, though oc- 
casionally invasion of the submaxillary capsule or the vascular interspace is 
observed. Early incision will allay pain, relieve the fever, and will prevent 
the extension of suppuration. 

The treatment of necroses of the mandible was disposed of elsewhere. 

(ft) Submaxillary and Parotid Cynanche. — Both the submaxillary and 
parotid salivary glands are inclosed in complete and very dense fascial en- 
velopes. On account of this anatomical peculiarity, and in the case of the 
submaxillary gland, the vicinity of the tongue and larynx, purulent inflam- 



218 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

mations of these organs present some peculiarly grave features worthy of 
special attention. 

Human saliva normally contains a chemical substance akin to the pto- 
maines or to snake poison, that, like the latter, seems to play an important 
part in the process of digestion. Whether an undue development of this 
albuminoid substance, or exclusively the direct absorption of septic matter 
from the oral cavity is at the bottom of the septic inflammations of the sali- 
vary glands, is not known — suffice to say, that occasionally one or the other 
of these glands becomes the seat of suppurative inflammation. Their resist- 
ant envelope leads to incarceration of ichor and pus, to the development of 
enormous tension and its deleterious local and general effects — which are 
dense infiltration and necrosis of the contiguous soft parts, with dysphagia 
and suffocative attacks, and a highly septic fever. 

Sublingual or Submaxillary Cynanche {Ludwig's Angina). — A painful, 
deep-seated, hard swelling of the submaxillary region appears, and is quickly 
followed by chills and high fever, the swelling rapidly increasing in extent 
and hardness, and the skin over the submaxillary gland turning dusky red. 
As long as the patient is up, his head is held rigidly in one position, the 
eyes moving in wide circle§ if he wants to see an object out of his range of 
vision. Or, if he be unsuccessful, the entire body is turned round slowly 
to bring the desired object within sight. The mouth is held slightly open, 
the tongue is dry, the floor of the mouth somewhat cedematous. Speech is 
difficult, as can be seen from the painful twitchings of the patient's face 
whenever he has to say something. After a while he will seek the bed. The 
face will appear slightly cedematous and cyanosed, the eye has a dull and 
stupid expression, the dry tongue is found lolling out of the mouth, and 
saliva escaping alongside of it. The floor of the mouth is very cedematous, 
and by this time the entire submaxillary region will have become swollen 
and as hard as a board. The labored snoring respiration of the patient gives 
warning of the extension of the oedema to the soft palate, fauces, and the 
vicinity of the larynx. The temperature indicates very high fever, and the 
patient is unable to allay his burning thirst, as swallowing will have become 
impossible. At this stage oedema of the glottis may cause asphyxia in some 
cases, requiring immediate tracheotomy. In other cases extensive slough- 
ing of the involved parts of the neck will supervene, and fatal haemorrhage 
may be caused by erosion of large vessels. The grave septicaemia alone, or 
the extension of septic thrombosis to the cranium or right auricle, may end 
in death. 

All dilatory measures, such as hot or cold applications, will be useless, 
or positively injurious, and the patient's salvation depends on a quick 
appreciation of the true character of the trouble, followed by prompt and 
energetic action. 

Case I. — It was observed by the author during his military service in Garrison Hos- 
pital No. 2 at Vienna, Austria, in November, 18*72. During convalescence from a severe 
form of typhoid fever, symptoms of sublingual cynanche appeared in a young soldier 
treated in the division for internal diseases. Fomentations being employed, the swell- 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 219 

ing assumed alarming proportions. Suddenly oedema of the glottis appeared, and the 
case was transferred to the surgical division. The left side and frontal region of the 
neck were found densely infiltrated and very hard, and tracheotomy had to he per- 
formed under unusual difficulties hy regimental surgeon Dr. Fillenbaum. A number 
of abscesses were encountered, and purulent perichondritis was found to be the immedi- 
ate cause of the oedema of the glottis. Tracheotomy relieved the dyspnoea, but the 
patient died soon afterward of septicaemia. 

Ca.se II. — Jacob H., farmer, aged twenty-one, admitted to the German Hospital 
January 19, 1886, presented a circumscribed red swelling of the left submaxillary 
region, that had appeared with high fever two days before admission. Face cyanosed, 
expression dull, breathing stertorous; the mouth half open, tongue protruding, floor of 
mouth oedematous. Temperature, 104*5° Fahr. Immediate incision according to Hil- 
ton-Roser's method in anaesthesia. About half an ounce of thin ichorous pus escaped. 
The incision was enlarged with a probe-pointed knife, and drainage and a moist dress- 
ing were applied. In the night a short suffocative attack appeared. January 20th. — 
Temperature, 101° Fahr. Cyanosis and oedema of the floor of mouth appreciably 
diminished. Improvement continued, no necrosis following, and patient was discharged 
cured February 6th. 

Case III. — William B., clerk, aged twenty-two. Sublingual cynanche, character- 
ized by protrusion of tongue and very high fever. The family attendant had treated 
the case for ten days by poulticing, and April 3, 1884, had incised the swelling in the 
submaxillary region. Relief followed, but in the night alarming dyspnoea, due to arte- 
rial haemorrhage, supervened, that rapidly distended all the interspaces of the left side 
of the neck, and threatened suffocation. April 5th. — Early in the morning trache- 
otomy was hastily performed by the author, who found the left side of the neck enor- 
mously swollen, and some bloody serum oozing out of the small external incision and 
from the oral cavity. The source of the latter bleeding was found in a sloughy per- 
foration of the floor of the mouth. As haemorrhage had ceased, only a drainage-tube 
was placed into the external incision, and a moist dressing was applied. The patient 
was doing well April 7th, when he was seen by the author the last time. Later on, 
the family attendant informed the author that another external haemorrhage had 
occurred during the process of detachment of the numerous sloughs, requiring deliga- 
tion of a spurting, probably the facial, artery. Patient recovered 

Case IV. — C. S., watchman, aged thirty-two. Sublingual cynanche of thirty-six 
hours' standing. Extensive hard infiltration of anterior and left side of neck. Dys- 
phagia, dyspnoea, tongue protruding. May 5, 1886.— Incision by preparation at Ger- 
man Hospital. The thickened capsule of the submaxillary gland being divided, a small 
cavity containing about a half drachm of ichorous pus and debris was exposed and 
drained. It just admitted the tip of the index-finger. Immediate improvement of all 
symptoms. Patient was discharged cured May 20th. 

Parotid Cynanche. — -This may develop independently or complicated 
with orchitis during and after acute infectious diseases, such as typhoid and 
scarlet fever, small-pox, or the measles, or may be the direct continuation of 
an attack of mumps. It is not as alarming in rapidity of development as 
the sublingual form, but is apt to be much more tedious on account of the 
gradual breakdown of the lobulated structure of the parotid gland. One 
lobe after another succumbs to the suppurative process, and an intermina- 
ble series of abscesses make their appearance. Generally perforation out- 
ward is the rule ; occasionally, however, perforation into the spheno-max- 



220 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

illary fossa, and extension into the intermuscular planes of the neck, with 
all its dangers, ensues. Necrosis of the interlobular septa is a common 
occurrence. On account of the necessity of avoiding the temporal artery 
and facial nerve, long incisions are impracticable. They must be small, 
and several should be made to afford sufficient drainage. 

Case. — H. S., merchant, aged fifty, commenced to suffer about Christinas, 1885, 
from a furuncle of the external meatus. This led to suppuration of the lymphatic 
gland normally found in front of the meatus, and, under a poulticing treatment, to 
an involvement of the parotid gland. The patient was seen by the author January 
11, 1886, and exhibited a large, non-fluctuating, very dense swelling of the right 
parotid region, with a temperature of 104° Fahr. His right eye could not be closed 
entirely (paresis of the facial nerve), and he was unable to separate the jaws to the 
slightest extent. Besides, repeated chills, sleeplessness, and the intense pain radi- 
ating to the diverse branches of the trigeminal nerve, had demoralized the man com- 
pletely. A vertical incision placed just in front of the external meatus by careful 
preparation released a large mass of pus. The relief was very great, and the patient 
left the house five days later to be treated at the author's office, where he repaired 
daily for many weeks longer, as the involvement and breaking down of new lobules 
of the parotid gland made frequent irrigation and constant drainage a necessity. He 
was discharged cured March 28th. By October the paresis of the orbicularis palpe- 
brarum had disappeared. 

(y) Acute Glandular Abscesses of the Anterior and Lateral Cervical 
Regions. — They are caused by absorption of active micro-organisms depend- 
ent on inflammatory processes of the oral and nasal cavities, the pharynx, 
larynx, the lower jaw, and the mastoid region. They have to be well dis- 
tinguished from cold or chronic abscesses of the same region. Their onset 
is sudden ; pain and fever rapidly develop, with deep-seated dense infiltra- 
tion, and gradually the corresponding side of the neck becomes cedematous. 
Inflammations in the oral cavity, the tongue, the larynx, and the lower jaw 
produce an involvement of the glands in the perivascular space. They can 
be felt somewhat in front of the sterno-mastoid muscle, extending upward 
toward the angle of the jaw, and are commonly known as "submaxillary" 
glands. Affections of the temporal, auricular, and mastoid regions, and of 
the pharynx, nasal cavity, and oesophagus, on the other hand, are generally 
followed by intumescence or suppuration of the glands situated in the in- 
termuscular space. They can be felt behind the posterior margin of the 
sterno-mastoid, and their suppuration is apt to extend in the direction of 
the supraclavicular space. 

The question of when to incise these abscesses should not be made de- 
pendent upon the presence of fluctuation, as the worst and most virulent 
cases will have wrought infinite mischief long before the appearance of 
fluctuation. In very virulent cases, marked by violent general symptoms 
and rapid local spread, incision should be made at once after Hilton-Roser's 
method, as relief from tension is the most urgent requisite to prevent slough- 
ing and possible erosion of vessels. Anaesthesia is indispensable. 

Where the symptoms are less violent, the spread less rapid, maturing of 
the abscess may be awaited in case the patients are very averse to an incision. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 221 

But the responsibility for the consequences of delay should be declined by 
the physician. 

Case. — Louis Lebowitsch, aged twenty-seven, presser. December 15, 1886. — Pain- 
ful hard swellings developed in the pretracheal and both submaxillary regions with a 
severe chill. Previous to this the patient had been suffering from a " sore throat " for 
a few clays. The family physician advised poulticing, which, as usual, was enthusiasti- 
cally attended to by the patient's female relatives. The swellings continued to grow in 
size; fever and sleeplessness were nnabated. December 25th. — Suddenly an enormous 
increase of the swellings in front and on the left side occurred, with dyspnoea and 
dysphagia, which induced, December 29th, the patient's transfer to Mount Sinai Hos- 
pital. Following a hasty summons the author found the patient sitting up in bed, his 
head held erect, the neck increased to double its circumference, its skin red, swollen, 
and shining like a large-sized sausage. Boggy fluctuation everywhere. Most intense 
thirst with absolute disability to swallow even fluids ; wheezing, long-drawn respira- 
tion with considerable dyspnoea, which became augmented to an alarming degree by 
the reclining posture. Examination of the fauces revealed a swelling of the retro- 
faucial soft tissues, and almo-t complete contact of the slightly intumescent tonsils. 
Two incisions, one behind the posterior margin of the sterno-mastoid muscle, the other 
a little below the thyroid gland, released about a quart of a dark-red gory liquid, streaked 
with pus. This was followed by an immediate disappearance of the dyspnoea, and the 
patient was able at once to allay his thirst by copious drafts of water. A digital ex- 
amination of the cavities opened by the incisions showed them to communicate freely. 
The pulsating carotid could be distinctly felt, lying exposed behind a large, roundish 
mass of blood-clot, freely projecting into the lateral cavity, and seemingly attached to 
the pharyngeal wall. 

Two stout drainage-tubes were placed in the incisions, the remaining clots were 
washed out by gentle irrigation, and a large, moist dressing was applied. The fever 
fell at once from 103° Fahr. to 100° Fahr., but rose the following day to 103° Fahr., 
as the incisions were clearly insufficient for the drainage of the enormous cavity. More- 
over, there was still considerable oozing present, and therefore it was deemed proper 
to anaesthetize the patient again, for the sake of a thorough exploration, drainage, and 
possibly prevention of further haemorrhage. A fluctuating place just above the clavicle 
was incised, and was found communicating by a narrow channel with the upper cavity. 
Both of the lateral incisfons were now united by preparation, the external jugular vein 
being first secured by double ligature and divided, and thus by this long incision the 
interior of the large abscess was exposed to view. The cavity extended from the 
clavicle to the base of the cranium. In it lay exposed the carotid artery and the jugu- 
lar vein, to the upper portion of which anteriorly a large, firm, and irregular clot was 
found adhering, indicating where the haemorrhage had come from. The loose clots 
were all cleared out, but the one adherent to the jugular was left undisturbed. Copi- 
ous oozing from the abscess walls was observed, and checked by a loose packing of 
iodoformed gauze, preceded by thorough irrigation. The patient was discharged 
cured on January 27, 1887. 

The preceding case vividly illustrates the dangers of protracted poultic- 
ing in deep-seated lymphatic abscesses. Sloughing of the wall of an adja- 
cent large vein caused a most serious complication by secondary haemorrhage. 
Arterial haemorrhage would have undoubtedly produced rapid suffocation. 

(8) Glandular Abscesses of the Temporal, Mastoid, and Occipital Re- 
gions. — Suppurative processes located in the external ear will occasionally 
30 



222 KULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

extend to one or more lymphatic glands, subfascially situated in front of 
the external meatus of the ear, and in close vicinity to the parotid gland. 
They produce very violent general and local symptoms, and require early 
attention, as a subsequent involvement of the parotid gland is very apt to 
occur. 

Suppuration of the mastoid cells is the most common form of extension 
of a purulent otitis of the external or middle ear. Its symptoms bear great 
resemblance to those of acute osteomyelitis, and require prompt attention on 
account of the possibility of necrosis and the involvement of the meninges, 
brain, or lateral sinus. Where intense swelling indicates the presence of 
purulent periostitis of the mastoid process, a free incision of all the soft parts 
down to the bone will often give great relief. But, where the interior of the 
cancellous structure of the mastoid process is the seat of the disease, noth- 
ing short of a free opening of its interior will avail. Formerly, this opera- 
tion was done with the aid of the trephine, an instrument the penetration 
of which is somewhat beyond the supervising control of the surgeon. At 
present mallet and chisel are used for this purpose with greater advantage. 
The chisel should be held tangentially to the external surface of the mastoid 
process, thin layers of bone being pared off in succession, until the suppurat- 
ing focus is freely exposed. Thus injury to the lateral sinus can be safely 
avoided. Copious irrigation with a warm solution of corrosive sublimate 
and a moist dressing are advisable. The cases in which early operating has 
prevented necrosis will heal very promptly. Necrosis will retard the cure 
considerably, and may require a second or even a third operation for the 
removal of sequestra. 

In neglected cases spontaneous perforation through the periosteum will 
occur, and an external abscess, located posteriorly to the sterno-mastoid 
muscle, will appear. The tendency of its extension is toward the "inter- 
muscular space," that is, downward into the supraclavicular fossa. 

Occasionally the process extends backward and upward upon the 
occiput. 

Case I. — Fred. Buths, baker, aged eighteen, admitted to ear department of German 
Hospital, December 17. 1883, with purulent catarrh of the middle ear and suppuration 
of mastoid cells. Wilde's incision and extraction of some sequestra from the external 
meatus were practiced by Dr. J. Simrock. A phlegmon of the left occipital region, 
starting from a sinus below the mastoid process, having set in, patient was transferred, 
March 25, 1884, to the surgical department. March 26th. — High fever and violent 
headache with vomiting. Several incisions laid open an irregular cavity situated be- 
hind the ear and extending downward toward the neck. On pressure, a large quantity 
of pus oozed out of a recess between exuberant granulations near the lower anterior 
angle of the parietal bone. These being scraped away, a sequestrum, about one square 
inch in circumference, and comprising the whole thickness of the skull, was extracted. 
Pulsation of the bottom of the cavity thus exposed was clearly discernible. Healing 
progressed without interruption, the purulent discharge from the middle ear ceased, 
and patient was discharged cured, April 17, 1884, with a deeply indented scar. In 
October, 1886, he presented himself, complaining of epileptic seizures that had appeared 
in July, 1886. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 223 

Case II. — E. X., merchant, aged twenty-five. Had been suffering from purulent 
otitis media for a long time. Suppuration of the mastoid cells, and formation of an 
external infraraastoidal abscess, led to incision, which was done by Dr. E. Gruening, 
under whose care the patient had been for some time. A phlegmonous inflammation 
of the neck following, January 22, 1882, a consultation was called, when a number 
of deep incisions back of the sterno-mastoid muscle were made, and the abscesses were 
drained. The probe felt bare bone in the mastoid notch. Subsequently a considerable 
quantity of bony grits passed away with the secretions, and the carbolic lotion injected 
into the drainage-tubes entered the oral cavity. End of March, the patient was dis- 
charged cured, and remained well until September, 1886, when he was seen by the 
author suffering from dementia. 

b. Mammary and Retro-mammary Abscess. — Excoriations and fissures, so 
common upon the nipples of nursing women, are the portals through which 
infection enters the multitudinous lymphatics of the mammary gland. A 
preparatory treatment of the nipples during the last period of pregnancy is 
the best jn-eventive of the formation of fissures. It should consist in molli- 
fying, and removal by bathing in warm soap-water, of the thick layers of 
effete epidermis, usually present around the openings of the lacteal ducts. 
The tender epidermis thus exposed will be hardened, and will become fit to 
resist the manifold injuries unavoidable during lactation. 

Should rhagades develop, a thorough disinfection with corrosive-subli- 
mate lotion (1 : 1,000), followed by touching of the fissures with a well- 
sharpened stick of nitrate of silver, will in most cases lead to a cure of the 
painful disorder. Nursing should be either stopped and the milk removed 
with the breast-pump, or, if continued, should be only permitted with a 
nipple-shield, until the fissure is closed. 

Disregard of these precautions will frequently lead to suppuration. 

A large proportion of the inflammatory processes of the breast are non- 
suppurative, the intumescence, redness, and occasionally smart fever being 
set up by a retention of the thickish milk of first lactation. Sometimes 
fluctuation will be felt, and, if an incision is made, no pus — only milk— will 
escape. Absence of _an infection by micro-organisms must be assumed in 
these cases, which, as a rule, get well without suppuration by simple topical 
treatment, consisting of the application of moist heat and methodical com- 
pression. 

Hence, not all cases of acute mastitis terminate in abscess. Winckel 
saw, in the Dresden Lying-in Hospital, ninety-one out of a total of one 
hundred and thirty-six cases of mastitis get well without suppuration. 
Therefore, topical treatment with the ice-bag or cold-water coil (by both of 
these the secretion of milk is materially reduced), or, if opposition to these 
be encountered, tepid or warm applications, aided by support and gentle 
compression of the breast, should be first tried. 

Should, however, fever and the local symptoms persist or increase, and 
fluctuation become apparent, incision and drainage are the measures to be 
applied. 

Abscesses of the mammary gland proper are either subcutaneous, then 
generally located about the nipple ; or are more deep-seated, that is, intra- 



22± RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

glandular. A third form of breast abscess is the suppuration of the loose 
connective tissue found behind the gland : retro-mammary abscess. 

Its location in the vicinity of the nipple and the early appearance cf 
well-defined fluctuation will readily characterize the subcutaneous abscess. 

When the deeper parts of the glandular tissue proper become the seat of 
an abscess, general swelling of the breast-gland is most prominent. The 
skin of the mamma becomes red and oedematous, and one or more pitting 
points can be soon detected. But the breast is freely movable as a whole 
upon the pectoralis fascia. 

In retro-mammary suppuration the breast is immovable, and firmly 
attached at its base. The glandular tissue is soft and normal, unless a 
combination of mammary and retro-mammary suppuration be present. 
Deep fluctuation can be detected by careful palpation. 

Incision of the more extensive abscesses of the breast should always be 
done under anaesthesia, as the unavoidable pain associated with thorough 
work is too great to be endured ; and the measures must be thorough to 
give a prompt result, as nothing is more unsatisfactory than an insufficient 
or improperly placed incision. Suppuration is not limited thereby, new 
points of fluctuation develop, and the interminable process, with fever, sleep- 
lessness, and the drain upon the system, lead to serious emaciation and 
lamentable demoralization of both patient and physician. Antiseptic pre- 
cautions, consisting of a thorough scrubbing of the surgeon's hands and of 
the patient's breast with soap and brush, and subsequent rubbing off with 
corrosive-sublimate lotion (1 : 1,000), should never be neglected. There are 
microbial cultures of various intensity of virulence, and the touch of an 
unclean finger may intensify an otherwise comparatively bland form of sup- 
puration, or may add the poison of erysipelas to that of simple suppuration. 

All incisions penetrating the glandular tissue should be placed radially, 
so as to avoid injury to the lacteal ducts as much as possible. 

A place of fluctuation being marked, the knife is rapidly thrust into the 
abscess, if the thickness of tissues to be cut through is not too great. In 
the latter case, Hilton-Roser's method is safer and preferable, on account of 
the possibility of haemorrhage from a deep-seated vessel. 

Note. — Billroth recounts a case in which he caused uncontrollable and very serious haemor- 
rhage by cutting a large branch of the external mammary artery. The loss of blood was alarm- 
ing, and so beyond control that, after having unsuccessfully tried a number of the usual measures, 
he finally injected the abscess cavity with a quantity of turpentine oil, that happened to be 
Avithin reach. The bleeding was stopped, but a formidable gangrenous phlegmon brought the 
patient very near the grave. She recovered, however. 

As soon as the well-dilated dressing forceps is withdrawn, the index of the 
left hand is slipped into the cavity, and a gentle exploration of its interior is 
carefully made. Wherever a recess extends toward the skin, the tissues are 
raised upon the tip of the left index-finger, the skin and fascia are incised, 
and the dressing forceps is introduced along the grooved director in the well- 
known manner. In this way a number of counter-incisions can be made 
with very little haemorrhage, Stout drainage-tubes, reaching just within 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 225 

the cavity, are next introduced, and the abscess is well washed out with the 
mercuric lotion. Oozing from the abscess walls, which is sometimes con- 
siderable, will also be checked thereby. After this the breast should be 
grasped and gently compressed between the extended hauds as a test, 
whether all recesses had been duly emptied or not. The appearance of 
additional masses of pus will be a proof tbat something was overlooked, 
and renewed search must be instituted to find and drain the overlooked 
recess. 

Note and Case. — The observance of this simple rule led to the recognition of a very interesting 
and rare form of suppurative mastitis. Mrs. C. F., primipara, admitted to Mount Sinai Hospital 
two weeks after her confinement, with abscess of the breast. Had very little fever. She was anaesthe- 
tized December 20, 1886, and, four fluctuating spots situated just above and near the nipple being 
incised, the finger was slipped into one of the incisions, and found the irregular and tortuous 
cavities communicating with each other. A large number of smaller cavities occupying the 
upper half of the mammary gland were entered, and the intervening bridges of tissue were 
broken down with the finger. Haemorrhage was very scanty. The cavity was washed out, and, 
gentle pressure being applied, an additional large mass of thick pus escaped. A long incision 
uniting the two most distant primary incisions, and passing through the entire width of the gland, 
was now made. It exposed the cavity, which was found lined with necrosed shreds of glandu- 
lar tissue. The abscess walls exuded on firm pressure from hundreds of invisible openings 
separate drops of creamy pus. A portion of the indurated wall of the cavity was pared off, 
until seemingly healthy tissue was encountered. Firm pressure being repeated, the same exuda- 
tion of pus from innumerable pores of the cut surface was observed. The section had a deep- 
yellow tinge, and presented the density of fibromatous tissue. The lower half of the breast-gland 
was normal and secreted milk. An iodoform dressing was applied, and remained undisturbed 
until December 27th, when the patient complained of pain and exhibited some fever. The 
dressings being removed, a new abscess was found and incised near the upper margin of the 
long incision. The old abscess cavity was granulating, but its walls still exhibited the peculiar 
appearance of a large number of distinct pus-drops on pressure. The wretched general con- 
dition of the patient, and the presumably interminable suppuration to be expected under the 
circumstances suggested exsection of the affected parts of the breast as the most rational 
measure. This step, however, was strenuously opposed by the patient, and she left the hospital 
uncured. 

Apparently we had in this case a form of purulent mastitis where the 
suppurative process was primarily located in the lacteal ducts, the intersti- 
tial connective tissue assuming the character of shrinking fibroid or cica- 
tricial tissue, as in non-suppurating interstitial mastitis. The contraction of 
the interstitial tissue led to closure of the lacteal ducts and to retention ; 
this to perforation of the lacteal ducts and extension of the sivppuration into 
the interstitial tissue ; this, finally, to the formation of a large number of 
disseminated abscesses and necrosis. Throughout, the case exhibited un- 
usual characteristics : well-circumscribed localization, low fever with appall- 
ing destruction of tissues, and their curious permeation with canals, that 
could be nothing but lacteal ducts, filled with creamy pus. As drainage 
and disinfection of the infected lacteal ducts were impossible, ablation of the 
diseased part of the gland was clearly the proper way to terminate the 
process. 

Retro-mammary abscesses usually point, near the lower margin of the 
breast-gland. They should be treated like other deep-seated abscesses, by 



226 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



incision and drainage, care being taken to establish the latter in the most 
dependent position. 

When the operation is completed, safety-pins are thrust through the pro- 
jecting ends of the drainage-tubes near the surface of the skin, and they are 
trimmed off short. A small ring of iodoformed gauze is placed underneath 
the safety-pin around the drainage-tube, to prevent its being overlapped by 
the edges of the wound, and a moist antiseptic dressing is applied. In the 
absence of fever and pain, and if the dressings remain unpermeated by secre- 
tions, they need not be changed before three or four days, when the drain- 
age-tubes can be either wholly removed, or one, having previously been 
somewhat shortened, can 
be left in the most de- 
pendent incision till the 
following change of dress- 





U 



\ 



¥\G. 



172 — Dressing for mammary abscess, 
or empyema. 



Where shreds of ne- 
crosed tissue are still ad- 
herent to the walls of the 
abscess, secretion will be 
somewhat more copious, 
and permeation of the dressings 
will require daily changes until 
the necrosed parts come away. 
During this time, however, if 
drainage be adequate, all the pus 
secreted should be contained in the 
dressings, and none in the tuound. After detachment of the necrosed parts, 
secretion will become scanty and watery in character, and removal of the 
tubes will be followed by rapid closure of the wound. 

In cases where drainage is inadequate, fever and pain Will persist, and 
secretion will remain profuse. The dressings will need frequent renewal, 
they will be rapidly soaked with pus, and the wound itself will contain 
more or less of it. This can be easily ascertained by gentle pressure, which 
will cause a copious flow of pus. Frequent irrigation is a very imperfect 
substitute of proper drainage ; therefore, the making of a well-placed incis- 
ion should remedy the shortcoming. 

c. Empyema.— Infection of the pleura by pyogenic organisms, either 
through metastatic processes or by direct extension from the bronchi and 
lungs ; from without by injury, or from purulent affections of the vicinal 
regions, as, for instance, perinephritic or liver abscess, leads to the forma- 
tion of empyema — that is, an accumulation of pus within the pleural cavity. 
The diagnosis of the affection is based upon the fever, dyspnoea, the absence 
of respiratory murmur, the dull percussion sound, rigidity of the affected 
side of the thorax, flatness of the intercostal depressions, and more or less 
marked oedema of the integument over the site of the accumulation. 

Probatory puncture with a hypodermic needle will usually yield pus. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 227 

The proper treatment consists of timely incision, disinfection, and drain- 
age under antiseptic cautelae. 

Management of Recent Cases of Empyema. — The thorax of the anaesthe- 
tized patient is cleansed and disinfected, and an incision is made, from two 
to three inches in length, in the eighth intercostal space, parallel with the 
ribs, and a little back of the axillary line. The skin and muscles are grad- 
ually divided down to the pleura, which is then incised. The sudden gush 
of pus is checked and moderated by the pressure of the tip of the finger, as 
too sudden evacuation of the tense accumulation may lead to rupture of ves- 
sels, or, in the case of empyema of the left pleural cavity, to fatal embolism 
of the pulmonary artery. In these cases the heart is displaced to the right 
side, and any clots that may have formed within the right auricle could be 
easily detached by a sudden change of the heart's position. This accident 
has occurred once to the author. However, it did not take place on the 
operating-table, but happened several days after the operation. 

Case. — Helen Muller, aged eleven. Empyema, with two fistula?, of six years' 
standing. Great emaciation ; retention of fetid pus; the heart displaced to the right 
side. February -27, 1883.— Exsection of two ribs, multiple incisions, and drainage of 
the fetid abscess. Daily irrigation produced a marked remission of the fever, and 
everything seemed to progress favorably, when, March 6th, while playing in bed, the 
child suddenly became cyanosed, and fell back dead. No post-mortem examination 
could be had. Death was doubtless caused by embolism of the pulmonary artery. 

The pleural incision should be ample, as otherwise voluminous fibrinous 
pseudo-membranes may clog the exit of pus. A large-calibered drainage- 
tube, reaching just within the pleural sac, is inserted, and is at once secured 
with a stout safety-pin, to prevent its being lost in the abscess. This 
occurred in one case treated at the German Hospital, and a good deal of 
trouble was experienced in finding the lost tube. 

Case. — Fridolin Jaehle, laborer, aged forty-three, saccated empyema of eight weeks 1 
standing. February 9, I884. — Posterior incision in tbe eighth intercostal space ; evacu- 
ation of a large quantity of pus. A drainage-tube was inserted, but slipped out of the 
fingers, and was lost in the cavity. The incision was sufficiently enlarged to admit two 
fingers, and then a sort of a diaphragm could be felt separating two intercommunicat- 
ing cavities. A counter incision was made in the mammary line, and the lost drainage- 
tube was extracted therefrom. Drainage-tubes properly fastened with safety-pins were 
inserted, and the cavity was irrigated with carbolic lotion. Moist dressings were ap- 
plied. April 18th. — Patient was discharged cured. 

Washing of the pleural cavity with warm mercuric solution (1 : 5,000) 
thrown from an irrigator should be done, until the fluid returns in a limpid 
state. Then a final flushing with corrosive-sublimate lotion of the strength 
of 1 : 1,000 should follow, and good care should be taken to drain off the 
last vestige of the solution by turning the patient so as to bring the incision 
nethermost. A very ample moist dressing should envelop the patient's 
thorax. 

As long as the temperature remains. normal or slightly elevated, and the 
dressing clean, no change is necessary. Usually, however, the dressings 



228 EULES OF ASEPTIC AND ANTISEPTIC SUKGERY. 

will bo soiled within twenty-four hours, and then they must be changed. 
But irrigation should not be employed so long as the patient's temperature 
is normal. Only, if renewed fever appear, or the secretion assume a fetid 
odor, will repetition of the irrigation be necessary. In fresh empyemata, 
especially of children, one irrigation thoroughly done at the time of the 
operation will be found sufficient. But in some favorable cases of adults 
the same smooth course of healing may be observed. The discharges will 
gradually diminish, they will lose their purulent character, and will become 
watery and scanty. As soon as this is observed, the drainage-tube should 
be removed, and within four or six weeks from the operation the cavity will 
be healed by renewed adhesion of the costal and pulmonal pleura. The 
lung will dilate to its normal extent, and the universal adhesion of the 
pleural surfaces will gradually give way to constant attrition, until the 
mobility of the lung and the normal state of things are re-established. 

Case. — Henry Fennell, furniture-dealer, aged thirty. Empyema on left side of four 
weeks' duration. February i, 1880. — Communication with a larger bronchus spon- 
taneously established, giving rise to uncontrollable fits of coughing, which have ex- 
hausted the patient to a dangerous degree. February 6th. — Incision, drainage, and 
irrigation with a five-per-cent solution of carbolic acid. The cough stopped at once ; 
the fever fell off. February 17th. — Discharge very scanty and watery ; drainage-tubes 
were removed. February 19th. — Sudden rise of temperature, with chill. February 
20th. — Pleuritic serous effusion on right side. March 1st. — Effusion on right side begins 
to be absorbed. Left lung dilated to nearly its normal compass. March 6th. — Exuda- 
tion in right pleura has disappeared. March 12th.— Patient was discharged cured. 

Lateral curvature of the spine is a prominent symptom of long-continued 
empyema, and is very hard to cure. The moderate amount of lateral curva- 
ture that goes along with recent empyema disappears with the restoration 
of the function of the compressed lung. 

Old Empyema. — Cases of inveterate empyema with or without sinus throw 
much greater difficulties in the way of the surgeon's efforts to close the cav- 
ity and fistula than recent cases. The retraction and consolidation of the 
lung, and its envelopment in more or less thick coats of pseudo-membrane, 
frustrate all attempts at closure of the thoracic cavity. The unyielding 
lung can not expand, while the contraction of the partially yielding walls 
of the thorax, accomplished by lateral curvature, by a close crowding to- 
gether of the ribs, and a corresponding flattening of the affected side of the 
chest, has its limits. Thus a secreting hollow space is maintained within 
the chest that can not be obliterated by the unaided efforts of nature, and 
ultimately the patient'sstrength and life will be sapped. The injection of 
irritating fluids, or the packing of the cavity with strips of lint or gauze, 
are of no avail, and the only means of effecting a cure is multiple exsection 
of the ribs according to the plan of Estlander. 

The rationale of this plan is to do away with the rigidity of the thoracic 
wall by removing suitably long sections of as many ribs as are found to be 
corresponding to the cavity. Thus the limbered thoracic wall may be 
depressed, and can be brought into actual contact, or nearly so, with the 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



220 




Fig. 173. — Cicatrix in a case 
of Est la rider's operation 
for inveterate thoracic fis- 
tula. (John Springer's 
case. ) 



opposite or pulmonal surface of the 
cavity, where it will be fastened 
down and retained by cicatricial 
adhesions that will form before the 
reconstruction of the exsected ribs. 
In due course of time the at- 
tached lung may even regain a large 
proportion of its former functional 
capacity by distention and aeration, 
and the more or less complete re- 
establishment of lung capacity is 
manifested by the disappearance of lateral curvature. 
Case I. — John Springer, clerk, aged twenty-one. Em- 
pyema of left side with thoracic fistula. Profuse secretion 
of pus, escaping through an insufficient incision. Exten- 
sive burrowing of pus under latissimus dorsi and serratus 
muscles. The process was of one year's standing, and had 
caused lateral curvature and far-gone emaciation. August 
25, 1879. — Incision and drainage of the external abscesses 
and of the left pleural cavity at the German Hospital. 
Exsection of the eighth rib became necessary, as the inter- 
costal space was too narrow to permit of a safe adjustment 

of the drainage-tube. The operation brought on alarming collapse, which was over- 
come by energetic stimulation. The external ab- 
scesses healed, and, though the secretion from the 
pleural cavity became much diminished, no tend- 
ency to a diminution of the capacity of the sac 
could be noticed. By New Year, 1880, the pa- 
tient's general condition had become excellent, and, 
no improvement being visible regarding the heal- 
ing of the thoracic fistula, January 3, 1880, Est- 
lander's operation was performed. By an ample 
vertical incision, commencing in front of the axil- 
lary space in the pectoral fold, the third, fourth, 
fifth, sixth, and seventh ribs were exposed. Their 
periosteum was slit up longitudinally, and sections 
of from two to four inches of the ribs were re- 
moved, the removed pieces being proportional to 
the entire length of the several ribs. As soon as 
the ribs were removed, the thoracic wall could be 
well depressed into the hollow of the cavity. In 
order to retard the new formation of bone, the 
external wound was packed with carbolized gauze, 
and healed by granulation. The pleural hollow 
began at once to diminish in size, and April 11, 
1880, patient was discharged cured. He has re- 
mained well ever since that time, and presented, 
April 23, 1887, when the accompanying photo- 
graphs were taken, the following status : A scarcely 
noticeable trace of lateral curvature ; the respira- 




Fig. 174.— Result after Estlander's 
operation. Absence of lateral curv- 
ature of spine. (John Springer's 



case.) 



31 



230 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

tory excursions of both sides of the thorax identical. All exsected ribs had re formed 
and occupied a normal position. Respiratory murmur could be heard all over the left 
side of the thorax. (Figs. 173 and 174). 

Case II. — Miss Eva 0., aged thirteen and a half. Thoracic fistula of two and a 
half years' duration, leading into a small cavity holding about three ounces of fluid, 
that had resisted all efforts at cure. May 12, 1881. — Exsection of sixth and seventh 
ribs at Mount Sinai Hospital. September 20th. — Patient was discharged cured. In 
August, 1882, the healed fistula came open, with pain and fever. September 26, 1882. 
— A sequestrum two inches in length, consisting of a portion of the seventh rib, was 
extracted. The wound healed promptly, and the girl's health remained sound. 

The author's rather incomplete record of all forms of empyema of chil- 
dren embraces twenty-two cases, All of these recovered with the exception 
of two — one died of basilar meningitis ; the other of pulmonary embolism. 

Of the nine cases of adults, four were cured by simple incision ; two by 
multiple excision of ribs ; one, a case of perforation of a tubercular lung 
cavity into the pleura, died of fatal haemorrhage into the pleura ; and two 
cases were discharged improved, but not cured. 

To conclude, it may be said that the earlier the operation, the safer it is, 
and the better the results achieved by it. 

d. Phlegmon of the Palmar Aspect of the Hand, of the Arm, and Axilla. 
— The hand, on account of its exposed position, is the most frequent place 
of small or more serious injury. The frequent necessity of the continued 
use of a slightly injured hand, and its contact with septic matter, lead to 
phlegmonous affections of different degrees of intensity. 

More serious traumatisms, like incised or lacerated wounds of the hand, 
become in numerous cases the seat of septic inflammation, in consequence 
of the improper and uncleanly primary treatment they receive from laymen 
and some physicians. Neglect of thorough cleansing and disinfection of 
a small wound often leads to direful consequences, that perhaps the most 
skillful and incisive therapy can not remedy. 

Of the manifold curious practices commonly employed for stanching 
haemorrhage and dressing injuries to the hand, only two may be mentioned. 
First comes the use of styptic solutions. They are unnecessary, because 
digital compression of short duration is capable of stanching even profuse 
arterial haemorrhage. 

The second practice is the favorite closure of soiled wounds about the 
hand with strips of adhesive plaster or a suture, without preceding disin- 
fection. 

Some of the worst forms of palmar phlegmon observed by the author 
were due to similar ministrations by lay or medical advisers. 

Case I. — John McG., liquor dealer, aged thirty -nine. April 30, 1886. — Chopped 
off the tip of his index-finger with a hatchet, and was attended to immediately by a 
medical quack, who strapped the injured part with a structure of neatly-arranged 
strips of adhesive plaster without previous cleansing. The wound was a smooth and 
clean-cut one, and offered the most advantageous conditions for the avoidance of infec- 
tion. Severe pain, swelling, and fever supervened on the following day, hut, at the 
advice of the medical attendant, the dressing was left on undisturbed for four days. 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 



231 



May 5, 1886. — The patient came under the care of the author, who found the wound 
and its neighborhood tightly compressed by the adhesive strapping, and a phlegmon of 
the sheath of the flexor and extensor tendons of the index extending into the inter- 
muscular planes of the ball of the thumb. A number of incisions exposed the necrosed 
tendons, and resulted in a tardy cure after their expulsion. He was discharged cured 
July 10th. 

Case II. — S. A., laborer, aged thirty-five. Presented himself in January, 1881, at 
the G-erman Dispensary with an incised wound of the palmar aspect of the thumb, 
and an extensive subaponeurotic phlegmon of the palm and forearm. The haemor- 
rhage had been unsuccessfully combated by the patient himself with applications of 
cobwebs and varnish. Finally, the aid of a druggist was sought, who soaked a piece 
of lint in perchloride-of-iron solution, and hermetically sealed the wound therewith. 
Phlegmon set in promptly, and rapidly extended to the palmar bursa. The styptic 
dressing remained undisturbed, but the palmar swelling was treated with diligent 
poulticing. At the German Dispensary various incisions were done in anaesthesia, fol- 
lowed by a tedious after-treatment consisting of repeated counter-incisions until cure 
was effected. The removal of the styptic lint, intimately matted together with living 
and necrosed tissues, was exceedingly troublesome. The function of the thumb was 
partially restored. 

Dorsum. — On account of the loose arrangement of the subcutaneous 
connective tissue of the dorsal region of the hand, its phlegmonous affec- 
tions present characteristics similar to those of any other subcutaneous 
phlegmon. The presence of a large number of hair-follicles favors the 
localization of septic processes in the cutis, which lead to the formation of 
typical furuncles or rarely a carbuncle. 

Palmar Aspect. — The peculiar features of the phlegmonous processes of 
the palmar aspect of the fingers and hand depend upon the anatomical pecu- 
liarities of that region. On 
the fingers we find, instead 
of the longitudinal and loose 
arrangement of the subcu- 
taneous tissue of the dorsum, 
a dense net- work of short, 
thick fibers, inclosing a num- 
ber of small acini of fat. The 
main direction of the course 
of these fibers is from the 
cutis down to the periosteum, 
or to the sheath of the ten- 
dons, to which they are close- 
ly attached. The direction of 
the lymphatics coincides with 
that of the connective tissue. 
Upon this centripetal course 
of the lymphatics depends the pronounced tendency of digital inflamma- 
tions to penetrate to the bone or the tendons. The well-known tendency 
to necrosis and the formation of cutaneous, tendinous, or osseous sequestra 
is, on the other hand, caused by great tension due to the rigid and dense 





& mm 






It 




Fig. 175. — Transverse section of terminal phalanx, show- 
ing arrangement and direction of connective-tissue 
(From Vogt.) 



fibers. 



232 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 176. — a, Blind endings of sheaths of the in- 
dex, middle, and ring fingers, b, c, Sheaths of 
thumb and little finger openly communicating 
with palmar bursa. (From Vogt.) 



ing to these three closed sacs three pom 
mar bursa, into which the tendons enter 
after passing through the sheathless part 
of their course. (Figs. 176 and 177.) 

Thumb and Little Finger. — Upon 
this arrangement is based the great im- 
port of the suppurations of the thumb 
and little finger, mentioned by the old- 
est medical writers, and well known to 
the common people. While gatherings 
of the index, the middle, and ring fin- 
gers often perforate spontaneously near 
or on the level of the finger-balls (where 
the blind end of the closed tendinous 
sheath coincides with the thinnest por- 
tion of the palmar aponeurosis), suppu- 
rations of the thumb and little finger are 
very apt to, and as a matter of fact often 
do, extend at once into the palmar bursa. 
The knowledge of this peculiarity is of 
the greatest practical importance. 



arrangement of the subcutaneous 
connective tissue. (Fig. 175.) 

The manner of the extension of 
phlegmonous inflammation within 
the tendinous sheaths of the pal- 
mar aspect of the hand is also pre- 
scribed by their special arrange- 
ment. Fig. 176 shows the sheaths 
of the flexors of the thumb and lit- 
tle finger in open communication 
with the common palmar bursa, 
through which pass all the flexor 
tendons of the fingers to and un- 
der the ligamentum capsi transver- 
sum, and hence to the forearm. 
The sheaths of the flexors of the 
index, middle, and ring fingers 
represent separate and "closed re- 
ceptacles, which terminate on the 
level of the metacarpophalangeal 
joints. For a short distance be- 
yond these sacs the tendons pos- 
sess no sheath proper, but are im- 
mediately inclosed by loose con- 
nective tissue. We see correspond- 
ted extensions of the common pal- 




Fio. 177. — Common palmar bursa injected, 
and showing extensions toward thumb 
and little finger. (From Vogt.) 



DIAGNOSIS AND TBEATMENT OF PHLEGMON. 233 

Aside from the acuteness of the symptoms, phlegmonous affections 
located on the palmar aspect of the hand and fingers present some pecu- 
liarities, the diagnostic significance of which must be mentioned. Redness 
of the shin is generally absent, to appear only when the process has worked 
its way up to the skin. (Edema is moderate, and is often overlooked by in- 
experienced observers, who are misled by the oedema and redness of the dor- 
sal soft parts to look there, and not on the palmar side, for the focus of the 
disturbance. 

The subjective symptoms are very distressing, high fever and intense 
pain being the rule. 

Treatment. — Prevention of phlegmon by guarding against the infection 
of large or small injuries of the integument is very profitable. Small 
excoriations and shallow cuts should be cleansed and touched with acetic- 
acid. Punctures should be well sucked and bled and sealed with an acetic 
acid eschar ; or, if there be the least suspicion of infection by an unclean 
sharp-pointed object, dilatation of the small hole, thorough wiping out of 
the track with sublimate lotion, and drainage by means of a few short pieces 
of catgut laid into the bottom of the puncture are to be employed. In this 
latter class of cases a moist dressing is appropriate. 

In the presence of an inflammation that is evidently gathering mo- 
mentum, all attempts at an abortive treatment are risky, as the deceptive 
relief afforded by hot applications is very apt to induce patient and physician 
to be tardy with the application of the best and surest antiphlogistic : the 
knife. By the time that the unbearable suffering finally compels energetic 
treatment, suppuration requires a long incision, and necrosis of a phalanx 
or tendon may be established. At first it might have been prevented by a 
much smaller incision — in fact, by a mere puncture. The cases where a 
timely deep puncture with a tenotomy knife released one or a few drops of 
pus to the most intense relief of the patient were very numerous in the 
author's dispensary experience, and he can not recommend this truly con- 
servative procedure in warm enough terms. Instead of a terribly painful and 
tedious illness ending in more or less of destruction, rapid healing of the 
small wound under the moist dressing will be the rule. And, if Ave consider 
that local anaesthesia by cocaine or the ether spray (both more effective if 
combined with artificial anaemia) has deprived incision of all its terrors, 
hesitation and poulticing become a culpable offense against the dictates of 
common sense. 

The diagnosis of the exact locality of beginning suppuration is easily 
made by the aid of the unmistakable sensations of the patient. Gentle 
pressure by a probe upon different points of the affected region, made to 
cover successively and in a methodical way the entire area in the shape of a 
spiral, will soon detect the most painful spot. If one or two repetitions of 
this process confirm the result of the first search, no hesitation need be felt. 
The point thus found is marked by a shallow scratch or otherwise, the 
finger or hand is anaesthetized, and the tenotomy knife is boldly thrust 
down to the periosteum. If a few drops of pus escape only, this will 



234 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



suffice ; if more, the puncture should be at once proportionately enlarged, 
thoroughly irrigated, and covered with a moist dressing. As the affection 
generally extends to the periosteum or tendon, the incision should always 
be carried down to one or the other, and should be longitudinal to avoid 
injury of vessels or tendons. 

Subfascial phlegmons of the palm should be also promptly and suffi- 
ciently incised. The adjoining diagram (Fig. 178) will be found very useful 

in pointing out the small area which should 
be avoided on account of the superficial pal- 
mar arch. It is situated between the first 
and last strokes of the capital M that marks 
the palm. After the aponeurosis has been 
cut through, any point of the palm can be 
reached from the lines marked out on Fig. 
178, by Hilton-Roser's method. 

Incision is advisable even at the risk of 
cutting the palmar arch, as the haemorrhage 
thus caused can be easily stopped by ligatur- 
ing the vessel in an ample incision, and Es~ 
march's band will effectively prevent undue 
loss of blood during the operation. 

There is no region of the human body 
where senseless poulticing of phlegmons has 
done more harm, and timely incision can do 
more good, than in the palm. 




U R 

Fig. 178. — Straight lines marking 
the places where incisions can be 
safely made. The space between 
the first and last strokes of the 
capital M, marking the palm, 
should be avoided. (From Vogt.) 



Case. — M. M., saddler, aged sixty-five, had in 
the latter part of August, 1885, a boil of the face, 
which he was in the habit of dressing himself. At 
the same time he infected a small scratch of his 
right forefinger, from which developed a felon. The 
family attendant ordered poulticing, which was kept 
up uninterruptedly for more than three weeks. Not one incision had oeen made, and 
when the author saw the patient, September 28, 1885, about twenty-four hours before 
his death from septicaemia, the hand and entire arm presented a terrible condition of 
phlegmonous destruction. Not one tendon, no joint, was free from suppuration, and 
a number of phalanges were necrosed ; the skin was extensively detached and repre- 
sented a boggy bag, from which pus flowed copiously through a number of smaller 
and larger defects due to sloughing. Diphtheria of the throat, tongue, and mouth had 
also developed the day before the consultation, and the wretched general condition of 
the patient put any operative measure out of question. The inquiry, how such a state 
of things could come about, drew the reply that "there were plenty of openings, they 
seemed to discharge freely and nicely, and therefore surgical interference was refrained 
from. 1 ' 

Neglected cases, where the suppurative process has attained wide pro- 
portions, should be treated on general principles laid down regarding the 
management of complicated abscesses. All recesses should be found out, 
separately incised, and drained. Where in the course of a long-continued 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



235 



process the soft tissues have been more or less permeated by the septic 
poison, and multiple small abscesses with a sanious discharge have estab- 
lished themselves, the enormous swelling will render efficient drainage very 
difficult or even impossible. 

Vertical suspension on Volkmann 's arm-splint with continuous irriga- 
tion will ofteu do here very effective service. Its detail is as follows : 

After the proper incisions are made and the requisite number of drainage- 
tabes have been inserted, the arm is enveloped in gauze, is loosely attached 
to the splint (Fig. 179) by a roller bandage, and is suspended from the ceil- 
ing or a suitable frame. One or more irri- 
gators filled with a very weak sublimated or 
salicylated lotion being also suspended, their 
nozzles are connected with one or more of the 
uppermost drainage-tubes. A rubber blanket 
is so arranged beneath the suspended limb as 
to catch all the drippings and to conduct 
them into a bucket placed alongside the bed. 
The flow of the irrigating fluid is regulated 
by pushing a match-stick or a straw into the 
nozzle of the irrigator. In this manner, ac- 
cording to necessity, a free current or the 
escape of the fluid in drops can be effected. 

If the entire limb require irrigation, the 
use of many irrigators can be obviated by a 
simple contrivance recommended by Starcke. 
A tin tube, open at one end, and provided 
with a number of nipples, is connected with 
a large irrigator. On the nipples rubber tubes 
are slipped, and are conducted to the several 
drainage-tubes, with which connection is es- 
tablished through short pieces of glass tubing. 
(Fig. 180.) 

Continuous immersion in a weak antisep- 
tic lotion is a very simple and effective sub- 
stitute for permanent irrigation, although it 
precludes the advantages of vertical suspen- 
sion. The lotion should be changed from 
three to four times daily, and its tempera- 
ture is to be regulated by the patient's sen- 
sations. Some will have it warm, others will 

prefer a cool bath. By placing one or two alcohol lamps underneath the 
tin vessel containing the bath, an even temperature can be maintained. 

Case I. — Hugo B., laborer, aged twenty -eight, admitted, March 11, 1886, to the 
German Hospital with extensive phlegmon of the palm, consequent upon an injury to 
the middle finger. The corresponding metacarpophalangeal joint was destroyed. The 
house-surgeon exarticulated the third finger, and made a number of incisions in the 




Fig. 179. — Volkmann' s arm-splint 
for vertical suspension. 



236 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



palm, liberating a good deal of pus. By March 12th the temperature had been some- 
what lowered, but an ominous swelling of the forearm appeared. March 18th. — A 
number of incisions were made on the flexor side of the arm into the suppurating 

tendinous sheaths. Moist dressings and elevated 
posture. Continuous high fever. March 25th. — 
Renewed incisions on dorsum of forearm, exposing 
the extensor tendons. Swelling of the arm and axil- 
lary glands. High fever. The affection proving un- 
controllable, on account of the uniform purulent 
infiltration of the soft tissues, continuous immersion 
of the limb in a 1 : 5,000 solution of corrosive sub- 
limate was resorted to, and was constantly employed 
during the months of April and May. No mercurial 
toxic symptoms whatever could be observed during 
this period of time. The swelling of the axillary 
glands disappeared a few days after the commence- 
ment of this treatment, and a tardy disappearance 
of the febrile symptoms followed pari passu with 
the detachment of a number of gangrenous muscles 
and tendons. Toward the end of May all the sloughs 
were detached, and the 
little finger was removed 
on account of necrosis of 
the phalanges. During 
June and July a number 
of small abscesses devel- 
oped on the hand and 
along the arm, and were 
successively incised. End 
of July all incisions were 
healed. Active and pas- 
sive motions and massage 
restored a part of the 
motion of the wrist, the 
thumb, and index. The 
patient, of whose limb and life we had despaired, was discharged cured and in a 
florid condition August 26th. 

Case II. — A. W., laborer, aged thirty-two, admitted, August IV, 1886, to German 
Hospital. August 7th. — Sustained an injury of the left forearm. The profuse haem- 
orrhage was stopped with a tourniquet. The physician left this instrument in situ r 
and ordered to tighten the screw in case of renewed loss of blood. The patient, fol- 
lowing the advice of his physician, tightened the tourniquet as directed. August 9th. 
— The forearm swelled up considerably, and assumed a bluish cast; at the same time 
several chills and high fever set in. Increasing swelling. A homoeopathic practitioner 
of Newark made a few superficial incisions, and, seeing no improvement therefrom, 
proposed amputation. On admission the patient presented a pitiable condition of sep- 
ticaemia. Temperature, 105 - 8° Fahr. The pulse was hardly noticeable, respiration 
ver}- frequent, the patient cyanosed and somnolent, his body covered with cold per- 
spiration. The entire left arm was enormously swollen, the skin of the forearm exten- 
sively discolored, and fluctuation was noted in many places. On account of the collapsed 
condition of the patient, only a few incisions were made to relieve the pus and to reduce 




Fig. 180. — Continuous irrigation by means of Starcke's tube, in 
vertical suspension. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 237 

tension. Aside from the large abscesses, a uniform purulent infiltration of the tissues 
was found. August 18th. — Numerous incisions were made in anaesthesia, the entire 
forearm exhibiting a state of ichorous infiltration. Necrosed portions of the skin and 
of various muscles were ablated, and a number of drainage-tubes were inserted. The 
arm was kept continuously immersed in a tepid bath for four days without an appreci- 
able improvement of the local or general disturbance. August 20th. — The arm was 
vertically suspended, and continuous irrigation by a weak mercurial lotion was estab- 
lished and kept up until September 18th. This change was followed by slow but 
unmistakable improvement, interrupted by occasional rises of temperature due to 
retention. The entire integument of the volar side of the arm was lost by necrosis, 
and the defect had to be covered by a number of skin-grafts. The patient was dis- 
charged cured November 29th, with slight mobility of the wrist and the metacarpo- 
phalangeal joints. 

By these means man} 7 a limb can be saved. The detachment of slough- 
ing tissues should be facilitated by the use of scissors and forceps, and the 
rule should be upheld not to sacrifice any part of the hand that is viable. 
Even the most sor^-looking, shapeless, and immovable rudiments of this 
useful organ will be of great value to the patient afterward. 

Should all these means be of no avail in checking the progress of sup- 
puration, amputation will have to be considered as a last life-saving remedy. 

Case. — Ernst B., shoemaker, aged sixty-nine. Had been for years attended to at 
the German Dispensary for a chronic fungous affection of the wrist. In the fall of 
1885 a phlegmonous inflammation started from one of the many fistulas present, grad- 
ually involving the entire hand, wrist, and part of the forearm. A large number of 
incisions had been made, but the trouble crept steadily from one joint to another, 
and along the tendons, until the hand presented one swollen, shapeless, festering mass. 
February 13. 1886. — Amputation of the forearm was done at its upper third. Primary 
union followed throughout. 

Joints of the Upper Extremity. — Injury and infection of the metacarpo- 
phalangeal or first inter phalangeal joints frequently take place during a 
rough-and-tumble tight, when the fist of a fighter hits the incisors of his 
antagonist. The author has treated four cases of this kind within the last 
seven years. In one, syphilis followed a very obstinate suppuration of the 
first interphalangeal joint of the right index. 

But often enough secondary suppuration of the finger-joints is caused by 
extension of a neglected subcutaneous or tendineal phlegmon. 

Note. — A very acute phlegmon of the elboic-joint came under the observation of the author 
at Mount Sinai Hospital. A compound dislocation was freshly admitted, and was reduced and 
dressed so-called " antiseptically " by a junior member of the house staff. Suppuration followed 
promptly, the sutures had to be removed, a number of incisions had to be made, and a tardy 
cure was effected, resulting in bony anchylosis of the elbow at an acute angle. (See case of 
Samuel Krongold, page 207.) 

Suppuration of the finger-joints usually terminates in anchylosis. In 
many cases this untoward result can be prevented by exsection and subse- 
quent careful treatment by passive and active movements. However, this 
operation should never be undertaken before the phlegmonous process has 
terminated, and suppuration has assumed a bland character. The author's 
32 



238 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

results achieved by this little operation are very satisfactory, and the pro- 
cedure can be warmly recommended. As a rule, a more or less movable 
joint results, which certainly is preferable to a stiff finger. In one case 
double exsection was successfully done after a felon of the thumb, involving 
the metacarpo-phalangeal and inter phalangeal joints. To this end, how- 
ever, preservation of the tendons is a necessary condition. 

Case I. — Frank P., liquor dealer, aged thirty-six. Seen January 15, 1885, with 
Dr. H. Balser, on account of a phlegmon of the right index and palm, caused by open 
injury to the metacarpo-phalangeal joint. The injury was sustained, January 1, 1885, 
during a fight by violent contact with the antagonist's teeth. The process had lost its 
virulent character, and subperiosteal exsection, by two lateral incisions, was done 
January 16th. The cure was uninterrupted. The flexor profundus tendon had sloughed 
away, hence only the first phalanx could be actively bent. Patient discharged cured 
February 22, 1885. 

Case II. — S. L., baker, aged twenty-nine. Seen in December, 1882, in consulta- 
tion with Dr. H. Kudlich. Eecent phlegmon of thumb, suppuration of tendineal 
sheath of flexors and of both the joints of the thumb. December 12th. — Three in- 
cisions released the tension. After the cessation of the acute stage of the inflamma- 
tion, December 29th, exsection of metacarpo-phalangeal and interphalangeal joints 
was done. Uninterrupted cure ; good function preserved. 

Phlegmon of the olecranic bursa is characterized by very acute local and 
general disturbance due to the great tension maintained by the dense cap- 
sule of the sac. Free incision supplemented by Volkmann's punctuation 
of the infiltrated skin of the vicinity is promptly followed by relief and a 
rapid cure. 

Suppuration of the cubital or axillary lymphatic glands is a very com- 
mon complication of limited or extensive septic inflammatory processes af- 
fecting the hand and arm. 

Two forms of suppuration have to be distinguished: One of an acute char- 
acter, terminating in the formation of one more or less extensive abscess, 
the result of confluence of several foci. A spontaneous or artificial evacua- 
tion generally leads to rapid cure. 

Another more chronic and very obstinate form, in which a group of 
lymphatic glands is attacked in succession, leading to the formation of a 
series of deep-seated abscesses and a number of sinuses. This form is gener- 
ally observed in poorly-nourished subjects. The individuality of the glands 
is not destroyed rapidly as in the more acute form, but their slow and 
gradual destruction is accomplished by a tedious ulcerative process. Long 
before the glandular ulceration is terminated, cicatricial contraction of the 
sinuses leading through healthy tissues will occur, and cause retention. 
This is followed by an exacerbation of the local and general symptoms, and 
results in the formation of a new abscess and sinus. The interminable 
suppuration often leads to serious deterioration of the general condition, 
marked by emaciation, night-sweats, and loss of appetite. As these cases 
represent an aggregation of a large number of septic foci imbedded in dense 
tissue, one or even more incisions will not be adequate for efficient drainage, 
and in spite of them the process will continue. 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 239 

Extirpation of the entire group of affected lymph-glands by careful 
preparation is their best therapy. As rupturing of one or more of the 
broken-down glands, and soiling of the wound by their contents, can not 
always be avoided, closure by sutures is best omitted. Thorough irrigation 
with corrosive-sublimate lotion, a loose packing with moist gauze, and a 
moist dressing are appropriate. 

Case I. — Emma Epple, servant, aged seventeen. Admitted to German Hospital 
March 31, 1886. As the consequence of a "run-around" treated by poulticing, sup- 
puration of the lymphatic glands of the left axilla developed. The arm-pit was filled 
with a densely infiltrated large mass of intumescent and very painful glands. The 
continuous fever and sleeplessness had produced an alarming degree of anaemia and 
debility, characterized by night-sweats and loss of appetite. As no fluctuation could 
be made out, and presumably all the affected glands were in a state of suppuration, 
extirpation of the entire glandular mass was advised, and carried into effect April 3d. 
Dissection of the tumor from the axillary vessels was rather difficult, and, one of the 
tenacula lacerating one of the brittle glands, a few drops of pus exuded into the 
wound. After thorough irrigation with corrosive-sublimate solution, the wound was 
closed by suture, and an antiseptic moist dressing was applied. Previous to this a sepa- 
rate incision was made at the most dependent portion of the cavity for the reception of 
a stout drainage-tube. A sharp chill and much pain followed the next day after the 
operation. Undoubtedly, infection of the cavity by contact with the escaped pus had 
taken place. The dressings being removed, pus was seen oozing out of the drainage- 
tube. Daily change of dressings and irrigation of the cavity with mercurial lotion was 
followed by rapid improvement, and the patient was discharged cured, May 7th. 

Case II. — C. H., butcher, aged sixty-two. Slightly cut the dorsum of his left 
middle finger, October 15, 1885, with a butcher-knife. A phlegmon developed, and 
was treated by the patient himself with poulticing till October 27th, when spontaneous 
evacuation took place. For a few days previous to this date, intumescence of the cu- 
bital lymphatic glands was noted. October 28th. — The patient came under the author's 
care with an angry swelling of the region of the cubital glands. Incision was proposed 
and declined. After a couple of wretched nights the patient consented to incision, 
which was done under chloroform, October 31st. A small amount of pus came away, 
and a drainage-tube and moist dressings were applied. The momentary improvement 
soon gave way to renewed attacks of pain and swelling, apparently due to succes- 
sive suppuration of several glands. Much difficulty was experienced in keeping the 
drainage-tube in situ, the external wound showing a great tendency to cicatrization, 
while the slow ulceration of the glandular tissue was still progressing. An extirpation 
of the glandular mass would have been more serviceable in this case than a simple 
incision. After a tedious and troublesome course of treatment, the case was finally 
discharged cured, December 27th. 

e. Suppurative Affections of the Lower Extremity : 

(a) Ixgkowx Toe-Nail. — The most common cause of this distressing- 
affection is the improper care of the toe-nails. Sweating feet, in combina- 
tion with lack of cleanliness, improperly trimmed toe-nails, and narrow-toed 
shoes, offer the best conditions for the development of ulcerative processes 
near the anterior edge of the nail. Whenever the nail is trimmed off too 
short, the adjacent skin will overlap its angle (Fig. 181). The epidermis be- 
ing macerated and soft from the profuse sweating, a small amount of friction 
between the edge of the nail and the skin will be sufficient to cause an exco- 



240 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 





Fig. 181. — a, Wrong way of trimmim 
toe-nail, b, The right way. 



riation. The pyogenic germs, so abundantly present in the fetid epideraridal 
masses of sweating feet, will not only come in contact with the raw surface, 
but will be rubbed into the open lymphatics by each successive step taken by 

the individual. An ulcerative inflam- 
mation of the parts will result, which 
offers poor conditions for natural drain- 
age. Retention of the septic secretions 
leads to chronic suppuration, and to 
the extension of the process backward 
toward the root of and also under the 
nail, until more or less of it becomes 
undermined and detached. Exuberant 
granulations, subject to frequent ulcer- 
ative destruction, spring up from the 
hypertrophied and infiltrated overlap- 
ping skin, and, if unchecked, the disorder terminates in the loss of the nail. 
Occasionally an ingrown toe-nail is the starting-point of phlegmon or ery- 
sipelas of the dorsum of the foot. The initial stages of the mischief can 
often be successfully met with a careful local treatment. Disinfecting baths, 
sprinkling of alum and salicylic powder (alum, usti, 3 ij ; acidi salicyl., 
I ss ; bismuthi subnitr., 3 ijss) into the stockings, which should be daily 
changed, and the packing of salicylated or iodoformed cotton or lint under 
the edge of the nail, frequently result in alleviation, if not a cure, of the 
affection. 

More inveterate or extensive cases in persons unable to devote the neces- 
sary care and time to the treatment of this trouble will be best cured by 
operation. After careful scrubbing and disinfection, the toe is rendered 
anaemic by constriction of its root with a piece of rubber tubing. Local 
anaesthesia is produced by either an injection of a cocaine solution or the 
use of Richardson's ether-spray. The 
point of a bistoury is (Fig. .182) 
placed against the exuberant tissues 
adjoining the nail, and is thrust 
through the margin of the toe. It 
is carried forward until the integu 
ment is separated in the shape of a 
longitudinal flap. Then the knife 
is reversed and carried back well be- 
yond the matrix of the nail, where 
the flap (c) is cut off. 

The pointed blade of a straight 
pair of scissors is placed under the an- 
terior margin of the nail (Fig. 182, A, b) just beyond the limit of the disease, 
and, being thrust under it, cuts through the nail in an autero-posterior direc- 
tion well back of the matrix. One blade of a stout pair of dressing- forceps is 
next insinuated into the slit in the nail and under the loose segment. This, 




Fig. 182. — Operation for ingrown toe-nail. 
a, b, Line of section through the nail 
and matrix. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 241 

being firmly grasped, is evulsed with an outward rotating motion. Good 
care must be taken not to leave behind any shreds of the cut-off matrix. 
Any granulations are scraped away with a sharp spoon, and the wound is 
well irrigated with mercuric lotion. A strip of rubber tissue well soaked 
in carbolic lotion, and just large enough to cover the wound, is placed next 
to it ; over this comes a strip of iodoformed gauze and a small disinfected 
sponge, the latter to exercise elastic pressure for the prevention of undue 
haemorrhage ; finally comes a light, compressive moist dressing, fastened 
by a roller bandage. While the patient's foot is held elevated, the rubber 
band is removed. The first dressing can be left on for a week or even two 
weeks. Being moist, it will peel off easily when removed, and, according 
to its size, the wound will be found either partly or entirely cicatrized over. 
Care must be taken not to compress the toe too much, as necrosis of the 
skin by pressure may develop and retard the healing. 

The author has treated over a hundred of these cases in the manner de- 
scribed with the best results, the majority being patients of the German 
Dispensary, who walked to and from the institution during the time of 
treatment. 

(b) Chromic Ulcers or the Leg. — Neglected excoriations or abrasions 
of the skin belonging to the lower third of the leg are the most common 
starting-point of ulcerous processes. Varices due to stagnation of the venous 
circulation render the progressive invasion of new areas of tissue by micro- 
cocci, ever present in the putrescent discharges, especially easy. Conse- 
quently, ulcerative destruction develops. The successful treatment of this 
condition must be based upon an elimination of the causal factors. Pre- 
vention or elimination of decomposition by antiseptics, and an improve- 
ment of the circulatory conditions by elevation of the limb or its elastic 
compression, form the cardinal points of our therapy. 

The affected limb is carefully cleansed with soap and a soft flannel rag 
until all the crusts of inspissated secretion and epidermis are removed. This 
process will be greatly facilitated by packing of the parts in strips of lint 
saturated with vaseline or un salted lard the night previous to the cleansing- 
bath. Plain water should never be used on account of its irritating quali- 
ties and its liability to cause eczema. After the bath the soap-suds should 
be simply wiped off with a soft towel. The ulcer is well mopped with a 
1 : 1,000 solution of corrosive sublimate, or, where the stench is very intense, 
with a 4 : 1,000 solution of permanganate of potash. Iodoform powder is 
dusted over the ulcer, and a suitable patch of rubber tissue is placed next 
to it. The eczematous skin in the vicinity is well anointed with vaseline 
or an astringent salve, and a regular antiseptic dressing is snugly bandaged 
on to the ulcer, the roller bandage extending from the toes to the knee-joint. 
This dressing need not be removed before two or three days, the frequency 
of renewal being dependent upon the quantity of the discharge. As soon 
as cicatrization is well advanced, a simpler dressing, consisting of a strap- 
ping of mercurial plaster covered with a pad of absorbent cotton, held down 
by a Martin's elastic bandage, can be substituted therefor, and the patient 



242 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

may be permitted to abandon the recumbent posture and take moderate 
exercise. When cicatrization is completed, a well-cleansed elastic bandage 
will suffice to prevent renewed ulceration. It is most convenient to have 
two elastic bandages, to be worn altera atingly. Under this simple treatment 
most ulcers of the leg, even those surrounded by callous edges, will develop 
healthy granulations, and will heal kindly. Due regard should be paid to 
the general condition of the patient, as on it may depend to a great measure 
the rapidity of the cure. A marastic state of the system should be improved 
by suitable nutritious diet ; the deterioration of the general health of those 
addicted to the immoderate use of alcohol should be remedied by a proper 
regulation of their habits. 

In cases of very extensive loss of integument, skin-grafting will give very 
gratifying results. If this should fail, circumcision of the callous ulcer by 
a deep cut carried through the fascia, according to Nussbaum, may be tried. 
The incision should be placed about one third of an inch from the edge of 
the sore. 

(c) Acute Suppuration of the Prepatellary Bursa. — Servant-girls 
and scrub-women, in short, persons frequently subject to house-maid's 
knee or simple synovitis of the prepatellary bursa, are frequently victims to 
phlegmonous inflammation of the same organ. The symptoms are those of 
a subcutaneous phlegmon, heightened by the circumstance that, the phleg- 
monous focus being encapsulated, great tension is apt to develop. Extensive 
necrosis and serious septic intoxication must result if no timely relief is 
afforded. 

Dense, hard infiltration and a deep-red flush of the prepatellary region, 
with oedema, high fever, and marked sickness, are present. The general 
intumescence may cause errors in diagnosis, as inexperienced observers are 
apt to look for the source of the trouble within the knee-joint. This mis- 
take can be avoided by noting that in septic bursitis the point of the most 
intense swelling, redness, and pressure-pain is over the patella, whereas in 
gonitis pressure over the juncture of the femur and tibia laterally of the 
patella is most painful, and the patella can be distinctly felt floating on top 
of the exudation within the knee. A free incision into the bursa, together 
with Volkmann's multiple puncture of the inflamed skin, is the proper 
treatment. The cavity should be well irrigated with corrosive-sublimate 
lotion, loosely packed with strips of iodoformed gauze, and inclosed in a 
moist dressing, which should be daily changed. 

(d) Acute Suppuration of the Knee-joint is one of the most formi- 
dable types of phlegmon. On its prompt recognition and energetic treat- 
ment may depend the safety of limb and life. It should be well distin- 
guished from the more bland, so called, " catarrhal''" (Volkmann) inflamma- 
tions of the synovial membrane, due to tuberculosis or to rheumatic and 
gonorrhceal influences ; and also from metastatic suppuration complicating 
pyaemia. 

It is generally caused by infection of the joint from without through 
accidental or surgical wounds, or by its invasion of a suppurative process 



DIAGNOSIS AND TEEATMENT OF PHLEGMON. 243 

established in the vicinity, as, for instance, acute osteomyelitis or a subcu- 
taneous or bursal phlegmon. Idiopathic acute suppuration of the knee- 
joint is very rare indeed. 

The invasion is marked by one or more sharp chills, very high fever, 
and a sudden painful intumescence of the joint. The limb is rotated out- 
ward, lying on its outer aspect, is flexed at an obtuse angle, and its position 
is carefully maintained by the patient, as the constant pain is terribly in- 
tensified by the least change of posture. General oedema and reddening of 
the integument soon follow, the septic intoxication frequently producing 
delirium and a typhoid condition. 

The intra-articular tension increasing, perforation of the capsule, gener- 
ally upward through the bursal extension of the joint beneath the quadri- 
ceps tendon, occurs, and is marked by a temporary remission of the in- 
tensity of the local and sometimes of the general symptoms. One or more 
subfascial or subcutaneous abscesses, located on one or both sides of the 
quadriceps, appear, and rapidly extend upward and outward until perfora- 
tion of the skin permits the escape of the enormous mass of pent-up pus. 
Occasionally the matter perforates backward into the popliteal space, this 
way being marked out by the bursae situated beneath the popliteus muscle, 
which are frequently in open communication with the knee-joint. In this 
case the abscess will extend downward along and beneath the muscles of the 
calf. 

Spontaneous perforation will not bring about complete and lasting relief, 
as the drainage is and must be inadequate. Profuse suppuration and a con- 
suming fever, with frequent chills and colliquative sweats, will in a short 
time so depress the patient's condition, that amputation will have to be 
thought of as the last resort for saving life. 

The treatment should be that of deep-seated phlegmon, modified by the 
requirements of the anatomical peculiarities of the knee-joint. The cavity 
of the knee-joint naturally consists of three distinct recesses : one below, the 
other above the patella ; the third is an extension of the suprapatellar space, 
and is known by the name of the bursa of the quadriceps. In flexion, 
where the knee-pan is firmly held down to the condyles, the infra- and 
supra-patellar spaces become practically non-communicating. Andrews of 
Chicago, to whom we owe a most excellent treatise on the subject of injuries 
to the joints, mentions a case * of traumatic suppuration of the infra- 
patellar recess of the knee-joint, where, by means of continued flexion and 
thorough disinfection and drainage of the same space, general infection of 
the joint was effectually prevented. 

To effect adequate drainage of a phlegmonous knee-joint, each of these 
recesses must be separately incised and drained. 

A double incision of each of these spaces will be much more effective 
than a single one, as it will permit more thorough irrigation. In very 
infectious cases two additional incisions will drain away pus retained in the 
reflection of the capsule from the vicinity of the crucial ligaments. 

* Ashhurst's " Encyclopedia of Surgery," vol. iii, p. 723. 



244 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The first incision should be made in the suprapatellar space on the 
inner side, where the capsule is the most ample. Haemorrhage is generally 
profuse, hence it is best to penetrate the tissues gradually, and to secure 
each bleeding vessel as soon as it is cut. As soon as the joint is entered, a 
dressing forceps is thrust through it to the corresponding point of the other 
side of the joint, where the second incision is to be made through the tissues 
raised by the pressure of the forceps. The point of the forceps emerging 
from this incision, a stout drainage-tube is grasped with it, and drawn into 
the joint just far enough to clear the synovial membrane. A similar piece 
of drainage-tubing is inserted into the first incision, and the protruding 
ends of the tubes, being transfixed with safety-pins, are cut off on a level 
with the skin. The infrapatellar and submuscular spaces are treated 
similarly, and, if necessary, the lateral pouches of the joint are also in- 
cised and drained. The cavities are thoroughly flushed out with corrosive- 
sublimate lotion, a large moist dressing is fastened on, and the limb is 
secured to a posterior splint to insure rest and painlessness during unavoid- 
able changes of posture of the patient. Wherever perforation of the capsule 
and formation of a circumarticular abscess has occurred, this must be sepa- 
rately incised and drained. 

In the great majority of cases, resolute and comprehensive measures of 
this kind will be rewarded by prompt improvement. Daily change of dress- 
ings and irrigation should be practiced until the disappearance of all the 
inflammatory and febrile symptoms. As soon as the discharges become 
scanty and serous, the drainage-tubes can be withdrawn one by one. Where 
the affection is due to osteomyelitis, anchylosis will result as a rule, espe- 
cially in grown individuals. In children, prompt and adequate drainage 
frequently results in preservation of mobility. 

Case I. — Charles Hundertmark, aged four. Acute suppuration of knee-joint caused 
by a blow upon head of tibia. May 31, 1875. — Three incisions — one on each side into 
the suprapatellar space, a third one into the quadriceps bursa. Daily change of moist 
carbolized dressings and irrigation. Kapid improvement. June 15th. — Drainage aban- 
doned. July Jfih. — Perfect recovery noted, with free active use of the joint. 

Case II. — John S., grocer, aged nineteen. Acute suppuration of knee-joint, with 
terrible pain and typhoid symptoms. The patient was brought to the German Hos- 
pital January 10, 1880, by Dr. Schwedler, who administered chloroform during the 
transfer, to allay the patient's suffering from the jolts of the carriage. Immediate typi- 
cal multiple incisions and drainage. The index-finger detected a roughened place on 
the articular surface of the inner condyle of the femur. Undoubtedly on account of 
the osteomyelitic process, the febrile symptoms receded very slowly. Permanent irri- 
gation of the joint rendered the frequent, terribly painful change of the dressings 
unnecessary. A few small sequestra belonging to the cancellous tissue of the femoral 
epiphysis came away on the twenty-third day. Patient was discharged cured, March 
20th, with firm anchylosis. 

In exceptionally neglected cases, where the process has assumed the 
character of a general purulent infiltration, incisions and drainage, supple- 
mented with continuous irrigation, will not be followed by as prompt im- 
provement as is desirable. The continued high fever, the formation of 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 245 

new abscesses, will certainly bring about a fatal termination, unless the 
limb is amputated clearly beyond the limits of the disease. So-called con- 
servative measures — as, for instance, exsection of the joint — are entirely 
inadmissible and dangerous under these circumstances. They will fail to 
remove from the affected parts the elements of contamination, as the most 
rigid antiseptic measures of the ordinary kind are here utterly inadequate. 
The phlegmonous process will attack the newly-made wound-surfaces, and 
the patient's life will be placed in the greatest jeopardy by secondary haemor- 
rhage. The following case forcibly illustrates the weight of these remarks : 

Case. — Max Loffmann, butcher, aged twenty. Admitted, October 25, 1885, to 
Mount Sinai Hospital. October 12th. — The submuscular recess of the knee-joint was 
accidentally incised with a filthy butcher's knife. Some synovia escaped from the 
small puncture ; after the accident the patient walked home. Suppuration of the knee- 
joint set in the following day, with rigors and general dejection. The wound was 
dressed by a Jersey City practitioner with an adhesive-plaster dressing placed over the 
incision. The patient was admitted to the hospital in a highly septic condition, large 
quantities of thin, ichorous pus escaping from the joint on slight pressure. Immedi- 
ately the patient was anaesthetized, and typical incision and drainage were done. The 
synovial lining of the joint was coated with a greenish-gray adherent and putrid mem- 
brane, in looks identical with the membranous coating in pharyngeal diphtheria. A 
number of small, purulent foci were opened by the incisions made for drainage of the 
joint. A moist dressing and dorsal splint were applied. In spite of frequent irriga- 
tion, no remission of the high fever or local pain following, amputation of the thigh 
was proposed, in view of the visible failing of the patient's strength. This, however, 
was resolutely declined by the patient and his widowed mother, who begged for an 
attempt to save the limb. The author, against his better judgment, performed exsec- 
tion of the knee-joint, November 6th. Esmarch's band was applied to the upper third 
of the thigh without the previous use of the elastic roller bandage, and a continuous 
stream of corrosive-sublimate lotion (1 : 1,000) was kept playing upon the wound during 
the entire operation, which was rapidly but carefully performed. Care was taken to 
operate in healthy parts, and all the involved tissues were removed. The wound 
was drained and closed in the usual manner, and the dressed limb was fixed upon 
a dorsal splint. Suppuration of the wound followed, requiring frequent changes 
of dressing and irrigation, the secretions retaining all the while their peculiar thin, 
ichorous character noted from the outset. On the afternoon of November 18th, pro- 
fuse arterial haemorrhage occurred from the wound, which was temporarily checked 
by the house-surgeon with the application of Esmarch's band. Being hastily sum- 
moned to the hospital, the author found the patient blanched and collapsed. About 
twenty ounces of a 6 : 1,000 watery solution of cooking salt were transfused into his 
median vein, and resulted in a notable improvement of the pulse. Amputation of the 
thigh was quickly done as a last resort. The patient, however, expired before the 
removal of Esmarch's band. 

Post-mortem examination revealed a sieve-like perforation of the popliteal vein 
and a large oblong defect of the popliteal artery, both of which were found exposed 
and surrounded by a massive blood-clot. The walls of the cavity containing the clot 
consisted of broken-down and necrosed tissues. 

There is little doubt that an early amputation might have saved the patient's life. 

(e) Supptjkation of the Inguinal Glands. — Two groups of lym- 
phatic glands have to be distinguished in the inguinal region — one situated 
33 



246 EULES OF ASEPTIC AND ANTISEPTIC SUKGERY. 

below Poupart's ligament, the other above it. The subinguinal group is 
frequently the seat of phlegmonous inflammation, due to absorption of sep- 
tic material from sores caused by the pressure of ill-fitting shoes, ulcerated 
bunions, ingrowing toe-nail, and excoriations of the lower extremity from 
scratching in eczema. Their treatment by incision does not require special 
elucidation. 

Should, however, their excision become necessary, the rules laid down 
for the removal of tumors from Scarpa's triangle (pages 50 and 53) should 
be heeded. 

Acute suppuration of the suprainguinal glands is caused most generally 
by ulcerative or suppurating processes of the generative organs. Their 
treatment is subject to the principles accepted for glandular abscesses of other 
regions, and may be dismissed with the remark that the best way to incise 
them is not parallel, but at a right angle with the direction of the fibers of 
Pouparfs ligament. The edges of the incision will gap asunder, and afford 
very good drainage even without the use of a tube, and, later on, the edges 
of the cut will not exhibit the tendency to become inverted, which is the 
source of much trouble in the after-treatment. 

Interminable chronic suppuration of the suprainguinal glands fre- 
quently indicates their bodily extirpation. The safest way of accomplishing 
their removal is as follows : Two semi-elliptic incisions should include all 
the fistulous openings leading into the glandular swelling. They should 
be gradually deepened until a comparatively healthy part of the swelling is 
exposed. Here the capsule is incised, and the mass is carefully dissected 
out with the tip of a pointed scalpel. Blunt dissection should be resorted 
to only where it is evidently easy, as in using much blunt force the glands 
may be ruptured, and their contents soil the wound. 

This injunction is important, as intentional or unintentional injury 
to the peritonmum may become unavoidable. Should the epigastric vessels 
be in the way, they must be cut and deligated. Attention ought to be paid 
also to the seminal cord, which occasionally enters into very close relations 
with inguinal glandular swellings. 

/. Perityphlitic Abscess : 

Arrangement of Connective- Tissue Planes of the Pelvis. — The extension of acute 
or chronic suppurative processes, originating in or near the pelvis, is prescribed by the 
anatomical arrangement of the peritonaeum and fasciae. This circumstance is the cause 
of the typical spread and outward perforation of pelvic abscesses. 

On account of practical reasons, three groups of pelvic abscesses deserve special 
distinction : 

1. All retro-peritoneal suppurations have the tendency to dissect up the anterior 
reflection of the peritonaeum. A fluctuating swelling is apt to appear above and cor- 
responding to the inner two thirds of Poupart's ligament. Perimetritic and peri- 
typhlitic abscesses belong to this group. 

2. The second group is composed of purulent accumulations that extend oeneath the 
fascia inclosing the psoas muscle. They generally leave the pelvis by the aperture be- 
low Pouparfs ligament, through which the ilio-psoas muscle emerges, and appear on 
the front of the thigh along the sides of the quadriceps. Their appearance is generally 






DIAGNOSIS AND TREATMENT OF PHLEGMON. 247 

accepted as an indication of the situation of the source of the suppurative process near 
the lower thoracic, or the lumbar vertebra?. 

3. The third group consists of abscesses that take their origin within the boundaries 
of the iliacus muscle, which occupies the internal aspect of the os ilium. Their exten- 
sion is prescribed by the limits of the iliacus, and they commonly appear on the surface 
below the anterior superior spine of the ilium, or more rarely in the loin at the exter- 
nal margin of the quadratus lumborum. The abscesses pointing below the anterior 
superior spine have no peritoneal investment, and can be freely incised without fear of 
injuring the peritonaeum. 

To sum up briefly, we may say that retro-peritoneal abscesses, as, for instance, peri- 
typhlitic or perimetritic gatherings, will generally point above and corresponding to the 
inner two thirds of Poupart's ligament. 

Psoas abscess, indicating affections located on the front part of the thoracic or lum- 
bar vertebras, will extend below Poupart's ligament to the front of the thigh. 

Iliacal abscesses, caused by suppurative affections of the os ilium, the sacro-iliac 
symphysis, or the sacrum, will generally point below the anterior superior spine of the 
ilium, occupying the outer third of the space above Poupart's ligament. Occasion- 
ally they will point in the lumbar region, or, when the abscess is very great, in both 
of the regions indicated. 

Inflammatory or ulcerative affections of the mucous membrane of the 
caecum or vermiform ap]:>endix, mostly due to fecal impaction or the pres- 
ence of foreign bodies, are often followed by phlegmonous processes estab- 
lished in the retro-peritoneal connective tissue located just behind the thick 
gut. Occasionally, but on the whole rarely, similar processes obtain on the 
left side of the abdomen, in the connective tissue behind the descending 
colon. 

Most commonly during adolescence a deep-seated, painful tumor de- 
velops in the iliac fossa, with more or less high fever, and gradually ex- 
tends to the groin. As the process approaches the surface, oedema of the 
integument and fluctuation appear. With very few exceptions the gathering 
is retro-peritoneal, and works its way outward along the posterior surface of 
the peritonaeum till it reaches to the anterior reflection of this membrane 
on a level of Poupart's ligament, where it becomes subfascial and subcutane- 
ous. This dissecting up of the peritonaeum by the abscess will assume very 
extensive proportions if the tension remains unrelieved for a long time. 
The author has observed burrowing of a perityphlic abscess into the pre- 
vesical connective-tissue space (case of Henry Marks). 

The danger of perforation of a perityphlitic abscess into the peritoneal 
cavity is present, but on the whole not very great. Only one case of this 
kind came under observation. 

Ca.se. — H. D., clerk, aged twenty. Subject to alvine sluggishness, contracted, after 
a more than usually severe spell of constipation, a deep-seated, hard, painful, peri- 
typhlitic swelling. Cathartics failed to relieve the bowels, and, high fever with vomit- 
ing having set in, the author was consulted. May i, 1878. — Typical swelling of a 
cylindrical shape was made out in the right groin, and a number of repeated large in- 
jections of tepid water into the gut were employed without success. May 3d. — The 
peritoneal symptoms, notably vomiting, became very distressing, wherefore this therapy 
was abandoned and opium treatment begun. At the same time an ice-bag was placed 



248 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 183. — Incising perityphilitic abscess. 



over the swelling. The change effected a decided improvement in the subjective symp- 
toms, but the swelling continued to increase and the fever remained unrelieved. May 
17th. — Spontaneous evacuation of a large, formed stool occurred. May 19th. — The 
general condition becoming very poor, incision was urged, but was firmly declined by 
patient and parents. Suddenly, in the night of the same day, perforative symptoms- 
developed. The patient died, May 20th, of septic peritonitis. 

Post-mortem examination demonstrat- 
ed an internal perforation of the abscess, 
and putrid septic peritonitis. Had the 
patient consented to the operation, the 
case might have turned out differently. 
Perforation took place on the nineteenth 
day after the invasion. 

The danger of perforation has 
been mnch exaggerated. It is very 
unlikely to occur in the early stages 
of the disease. Its exaggeration has 
frequently led to hasty operations, 
injury of the peritonaeum with its 
contamination by the escaping fetid 
pus, and fatal peritonitis. The practice of searching for pus with a hollow 
needle in the first three or four days of the disorder is also fraught with 
danger. The abscess not having pushed up and out of the way the perito- 
neal reflection, this may be doubly perforated by the instrument. Hilton- 
Roser's method is also unsafe in the early stages of perityphlitic or retro- 
colic abscess for the same reasons. 

Oa.se. — Francisca Bertrand, aged forty -five. Was taken ill with fever early in 
July, 1882, and developed a deep-seated, painful swelling in the left iliac fossa, with 
high fever and peritonitic symptoms. On the afternoon of August 5th, probatory 
puncture brought out some pus, wherefore, with the aid of the family physician, Dr. 
Assenheimer, incision was practiced by Hilton's method. A large quantity of pus 
escaped, and a drainage-tube and antiseptic dressing were applied. In the following 
night very acute peritonitis set in, to which the patient succumbed August 6th. No 
doubt the reflection of the peritonaeum was injured, and part of the pus must have 
entered the peritoneal cavity. 

Where symptoms of special urgency seem to indicate early interference, 
the approach of the abscess has always to be made by gradual and careful 
dissection, layer by layer, just as for deligation of the external iliac artery. 
The reflection of the peritonaeum must be found, carefully raised, and held 
aside. After this a probatory puncture, made in the bottom of the wound, 
will be safe, and, pus being found, a vent for the escape of pus by Hilton- 
Roser's method may yield satisfactory results. 

To sum up, it may be said that incision is most dangerous at that stage 
of the development of the abscess when the peritonaeum has become infil- 
trated, but is not yet raised up and pushed away from the abdominal wall 
by the contents of the abscess. This generally is the case on from the 
fourth to the seventh day. Before this, dissection and recognition of the 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 249 

peritonaeum are easy, but in many cases may be unnecessary, hence can not 
be commended. 

The safest way is to wait till the eighth or tenth day, or until fluctua- 
tion is evident, when the peritonaeum is well raised up, and the danger of 
its injury very remote. 

Case. — Jack Schlosser, aged ten. Had an attack of typhlitis in November, 1885, 
from which he promptly recovered. June 4, 1886. — Perityphlitis was again diagnosti- 
cated by Dr. Koehler, and, under the administration of mild laxatives and enemata, the 
condition of things seemed to improved up to the 10th, when higher febrile symptoms 
set in, and the area of painful intumescence in the right groin became notably en- 
larged. June 13th. — The diagnosis of abscess was made out. June llfth. — The author 
incised and drained the cavity with the aid of Dr. Koehler, under whose care the case 
improved rapidly, and was cured June 30th. 

Digital exploration of the cavity is very advisable, for two reasons : First, 
it will lead to easy detection and removal of foreign bodies, as, for instance, 
kernels or stones contained in the bottom of the abscess ; and, secondly, it 
will enable the surgeon to form a just conception of the extent and direction 
of burrowing sinuses, which may require separate drainage. 

Case. — Henry Marks, aged seventeen, suffered from habitual constipation and fre- 
quent attacks of colic. In June, July, and August, 1878, severe attacks of colic were 
noted and overcome by the use of purgatives. August 25th. — Dr. L. Weiss, the family 
attendant, made out typhlitis and ordered a laxative, which, however, failed to relieve 
the patient. Thereupon opium was methodically exhibited until September 6th, when 
the patient had a spontaneous and copious, formed evacuation. September 7th. — The 
temperature rose to 104° Fahr., the external swelling in the right groin became very 
marked. September 10th. — The author saw the patient in consultation with Dr. Weiss. 
A uniform puffy swelling was found occupying the right groin, and was extending 
beyond the median line of the abdomen. Frequent urination distressed the patient a 
good deal, who exhibited the usual hectic symptoms of long-continued suppuration. 
Deep fluctuation was made out, and evacuation of the abscess was determined upon. 
The transversalis fascia being gradually exposed, it was found infiltrated and firmly 
attached to the underlying tissues. A probatory puncture made in the bottom of the 
wound, close to the os ilium, gave pus, whereupon the abscess was freely incised, and 
a large quantity of matter was voided. No foreign body could be found. Digital 
exploration demonstrated a long sinuosity extending toward the median line to a pocket 
occupying the prevesical space. A drainage-tube was placed into the main abscess, 
and another one was carried into the prevesical space, and the wound was dressed with 
carbolized gauze. The patient's wretched condition at once commenced to improve ; 
appetite and sleep returned, and the profuse night-sweats disappeared. September 
20th. — The drainage-tubes became disarranged, and were found slipped out of the 
wound. Difficulty was experienced in replacing them, and symptoms of retention, 
with renewed pain and fever, set in again. September 23d. — The author again saw the 
patient, and replaced the tubes. A considerable quantity of pus was found in the pre- 
vesical pocket. From this date on uninterrupted improvement was noted, and the 
patient got up October 10th. October 20th, the tubes were withdrawn, and October 
30th the fistula was closed. 

As previously mentioned, stercoral ulceration of the intestinal mucous 
membrane is the most common cause of perityphlic abscess. This impac- 



250 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

tion of faeces is ordinarily located in the caecum or in the vermiform appen- 
dix. But occasionally, where a cancerous stricture of the ileo-caecal valve 
is present, it will be found located in the lowest part of the ilium, causing 
great distention, ulceration, adhesive attachment, and perforation into the 
retro-colic connective-tissue space, simulating perityphlitic abscess. 

Case. — Mr. M. G., aged sixty-two, had been suffering from habitual and very obsti- 
nate constipation for years. In May, 1880, profuse diarrhoea set in, and could not be 
controlled by any of the usual dietary aDd therapeutic measures. A grave deterioration 
of the general condition developed, and the patient lost very much flesh in spite of 
forced feeding. August 31st. — Fever set in, and the presence of a painful swelling in 
the iliac fossa was made out. September 3d. — The author saw the case in consultation 
with Dr. W. Balser and Dr. L. Conrad. A large fluctuating swelling occupied the 
right half of the pelvis, and tympanitic percussion sound was noted in the lumbar 
region. Two incisions were made— one above Poupart's ligament, another in the 
lumbar region — and an enormous amount of gas, pus, and fecal matter was evacuated. 
Profuse secretion and diarrhoea continued, and the patient died September 22d. Post- 
mortem examination revealed a tight cancerous stricture of the ileo-caecal valve, and an 
enormous dilatation of the lower portion of the ilium, which resembled thick gut. 
Large masses of impacted fecal matter were found in this pouch, which was adherent 
to the posterior parietal peritonaeum, and was freely communicating through a number 
of ulcerous defects with the abscess cavity. 

Flexion of the thigh upon the pelvis is a very constant symptom of peri- 
typhlitic abscess, and is in children occasionally the cause of an erroneous 
diagnosis of hip-joint disease. But hip-joint disease may undoubtedly be 
caused by the extension of a perityphlitic abscess along the ilio-psoas muscle 
to the iliac bursa, and hence into the hip-joint. 

Case. — Ernestine S., servant-girl, aged nineteen, admitted March 2, 1880, to the 
German Hospital, with the diagnosis of hip-joint disease, the symptoms of which were 
indubitably present. Emaciating fever, and the characteristic flexion and adduction 
of the thigh, together with swelling of the gluteal and infrapubic regions, seemed to 
admit of no doubt. Examination under ether, however, revealed a fluctuating swelling 
of the right groin, which yielded pus on puncture, and was incised. A large quantity 
of pus and the stem of an apple or pear were evacuated. Another incision below 
Poupart's ligament established drainage of an abscess communicating with the peri- 
typhlitic gathering. The lower extremity was put into Buck's extension, and the 
cavities were daily irrigated. Operative measures, directed against the profuse dis- 
charge from the lower incision — that is, drainage or exsection of the hip-joint — were 
contemplated, when the girl contracted erysipelas, and died of it in May, 1880. Post- 
mortem examination established the fact of hip-joint suppuration, a communication of 
the perityphlitic abscess with the joint being found, by way of the iliac bursa. 

Of sixteen cases of perityphlitic or retro-colic abscess observed by the 
author, fifteen were operated on, and twelve recovered. 

Three died — one of septic peritonitis, due to injury and infection of the 
peritonaeum at the time of the operation ; one from exhaustion, due to 
cancer of the ileo-caecal valve and ulcerative enteritis ; and one, complicated 
by hip-joint suppuration, from erysipelas. 

One case was not operated on, and died of septic peritonitis caused by 
perforation of the abscess into the peritoneal cavity. 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 251 

Four more cases of perityphlic inflammation, not operated on, but 
treated with opium and large enemata, recovered. In two of these marked 
tendency to relapses and habitual constipation persist. 

g. Abscess of the Liver. — The diagnosis of hepatic abscess is based 
upon the presence of a painful and growing intumescence of the liver, ac- 
companied by more or less intense fever, which gradually assumes a hectic 
character. In the beginning the swelling ascends and descends at respira- 
tion ; but later on, when the liver becomes attached to the abdominal wall, 
this mobility disappears. Probatory puncture with a fine aspirating needle 
can be safely made, and will generally dispel any doubt. As soon as the 
diagnosis is secured, incision has to be made. 

Where adhesion of the hepatic swelling to the abdominal wall is estab- 
lished, or, even more so, where the suppurative process has involved the 
integument, a free incision can be safely made. A large-sized drainage-tube 
should be inserted into the cavity, and frequent irrigation should be em- 
ployed. The wound is covered with an ample moist dressing. 

The incision of hepatic abscesses located in the unattached liver require 
some special precautions. The abdominal wall opposite the tumor is incised 
under a strict observance of the rules laid down for laparotomy, so as to 
expose the liver. The incision is packed with iodoformed gauze, and a dry 
dressing is applied. 

In three days firm adhesions of the liver to the abdominal wall will be 
established, when, the. packing being removed, the liver is punctured, and, 
pus being found, is freely incised and the cavity evacuated and drained. 

li. Lumbar Abscesses. — The significance of acute lumbar abscesses de- 
pends upon their causation and upon the locality from which they take 
their origin. The majority of lumbar abscesses are caused by purulent 
affections of the kidney or its pelvis — as, for instance, by renal calculus 
or pyelitis— but in a comparatively large number of cases no affection of the 
kidneys or their adnexa can be recognized, and traumatism of one or another 
kind must be assumed as the causative agent. 

Contusion and a sudden and unexpected strain of the back were stated 
to the author by patients as causative factors. The beginnings of lumbar 
abscess are always obscure and insidious. A deep-seated unilateral pain in 
the small of the back is first complained of. One or more chills or a low 
form of hectic fever set in. The patient's back is bent upon the affected 
side, and is more or less tender. Loss of vigor and emaciation become more 
and more evident, until a distinct tumor, marked by dullness on percussion, 
can be made out in the space between the crest of the ilium and the twelfth 
rib. The way of extension of the abscess is prescribed by the quadratus 
lumborum muscle, the outer edge of which serves as a landmark for finding 
and incising it. The presence of pyelitis or pyonephrosis, ascertained by 
examination of the urine, is very significant, and possible doubts as regards 
the nature of the trouble may be dispelled by one or more probatory punct- 
ures with a well-disinfected hollow needle and the aspirator. A good-sized 
caliber should be selected, as grumous or flocculent pus is apt to clog a 



252 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 184. — Lange's position for rem 
operations. 



and perirenal 



small-sized needle, and a negative result may be arrived at in the presence 
of a large collection of matter. 

Case. — Mr. I. A., brewer, aged twenty-two, developed lumbar pain and swelling 
of the right side without any known cause. April 17, 1881. — High fever accompanied 
the seizure, and, though no fluctuation could be felt, the diagnosis of perinephritic 
abscess was made. April 21st. — In the presence of Dr. Heppenheimer, the family phy- 
sician, four probatory punctures were made with an aspirator needle without positive 
result, and, unfortunately, the contemplated incision was deferred until the next day, 
when perforation into the pleura and rapidly fatal pyothorax developed. 

Had a larger-sized needle 
been used, pus would have 
been found, and the fatal 
termination might have been 
averted by timely incision. 

Early incision can never 
do any harm where perine- 
phritic abscess is suspected, 
and will be of some use even 
if pus be not found at the 
first attempt. On account 
of the deep situation of the 
abscess, and the necessity of 
exploring its interior for sinuosities, which may require separate drainage, 
an ample incision is advisable. It should be done in anaesthesia under 
strict antiseptic precautions, and by gradual dissection. 

The patient is brought into the position recommended by Dr. F. Lange 
for nephrotomy. A roll made of a blanket is slipped under the lumbar re- 
gion, and the body is placed semi-prone 
upon the affected side, as shown in the 
accompanying cut (Fig. 184). The vicin- 
ity of the swelling is carefully cleansed and 
disinfected, and the surrounding parts of 
the body are protected with rubber cloths 
and towels in the usual manner. A lon- 
gitudinal incision two or three inches in 
length is made, commencing about an inch 
below the last rib, and extending to near 
the crest of the ilium, and is gradually 
deepened until the abdominal muscles are 
all divided. Frequently pus will be reached 
before the edge of the quadratus lumborum 
muscle is exposed. Should this not be the 
case, a grooved director may be inserted un- 
derneath the external margin of this muscle, 

and, being pushed downward and toward the median line, will soon enter the 
abscess. As soon as pus is seen to appear in the groove of the instrument, 




Fig. 185. 



-Incising perinephritic 
abscess. 




DIAGNOSIS AND TREATMENT OF PHLEGMON. 253 

a dressing-forceps is insinuated into the cavity, and is withdrawn while held 
wide open. Blunt dilatation of this kind can be repeatedly practiced until 
the aperture is large enough to admit the index-finger for exploration. 

Should the abscess contain urinous matter or stones, or should the septa 
of the calices of the renal pelvis be recognized by touch, the causation of 
the process by perforation outward from a suppurating kidney will suffer 
no doubt. If found, stones may be then extracted, and the cavity, being- 
well washed with boro-salicylic lotion, is drained by the insertion of one or 
more stout rubber tubes. 

Xote. — A very efficient mode of draining is the following one : A number of fenestra are 
cut into the sides of a large-ealibered rubber tube, which is placed well within the cavity. An- 
other smaller-sized tube of 
the same length is pro- 
vided with a couple of 
fenestra near its mesial 
end, and is inserted into 
the abscess alongside of 
the larger tube (Fig. 186). 
A stream of lotion inject- 
ed into the smaller tube 
will enter the bottom of 

the abscess, will wash out FlQ i 86 ._Arrangement of drainage-tubes for perinephritic or any 

its recesses, and will carry other deep-seated and large abscess cavity. 

away secretions and debris 

through the many fenestra of the larger tube. Safety-pins thrust through the distal ends of the 

tubes will prevent their being lost in the abscess. An ample antiseptic moist dressing should 

envelop the entire lumbar region, and the patient should be brought to bed. 

In opening perinephritic abscesses, the author has met with two cases 
in which the pus had a peculiar whitish-yellow color, the consistency of 
curdled cream, and the odor of freshly-made warm whey. In both of these 
cases death caused by uraemia followed some time after the incision, and 
post-mortem examination showed that the parenchyma of the kidney had 
been destroyed, and that the organ was a pus-bag with fibrous walls, which 
were perforated and communicating with a number of secondary abscesses 
located in the pelvis. The secretions contained tubercle bacilli. 

Case. — Emil Colin, clerk, aged thirty. Pyelonephritis of many years' standing. Very 
marked anaemia and high fever, with a large lumbar and pelvic swelling, that was first 
noted in February, 1886. Incision, done April 28, 1886, at the German Hospital, evacu- 
ated an enormous amount of the above-mentioned peculiar smelling pus. The tempera- 
ture was at once reduced to nearly the normal standard. As the cavity contracted, and 
the secretion became scanty, the house-surgeon withdrew the tube, whereupon retention 
in the pelvic part of the abscess with renewed fever compelled, May loth, dilatation 
and replacement of the tubes. The evacuation of the abscess was not followed by an 
improvement of the quality of the urine, which continued to contain pus and hyaline 
casts, showing that the other kidney was also affected. Death from uraemia, May 10th. 

Cases of surgical kidney may get cured after the extraction of stones, if 
portions of the renal parenchyma be preserved, and continue to secrete 
urine, and the ureter be unobstructed by calculi or cicatricial stenosis. 
34 



254: 



EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 187. — Dressing for lumbar or hepatic abscess. 



Should the latter conditions prevail, a urine fistula will persist, and removal 

of the kidney may come in question. 

In cases where the kidney has lost its identity, but no complicated and 

unfavorable topographical conditions of the abscess cavity are present, a 

cure may also follow incision 
and drainage. 

Where the relations of the 
abscess are unfavorable — that 
is, the kidney consists of a 
number of communicating or 
separate abscesses — debili tating 
suppuration may baffle the ef- 
forts of the surgeon for a long- 
time. It is best in these cases 
to await the contraction of the 

walls of the main abscess of the kidney before proceeding to the extirpa- 
tion of the organ. 

Lumbar abscesses, the relation of which to purulent affections of the 

kidneys is unlikely or doubtlessly absent, admit of a much better prognosis. 

They are frequently referred by the patients to traumatisms, and, properly 

incised, heal very promptly. 

Case. — A. F., pawnbroker, aged twenty-four, sustained, in May, 1885, in jumping 
and slipping, a severe strain of the left side of the small of the back, which was fol- 
lowed by sharp pain and stiffness for a few days. It subsided spontaneously, but left 
behind a soreness of varying intensity. May 20, 1886. — Fever set in with intense lum- 
bar pain, but swelling came on very slowly. Though looked for, it could not be made 
out until July 10th, when Dr. E. Schwedler ascertained its presence. The kidneys, 
gut, and spinal column were found normal. July 12th. — Incision by gradual dissection 
was practiced under ether. The abdominal muscles being divided, the edge of the 
quadratus lumborum was exposed. Probatory puncture in the bottom of the wound 
had to be done five times before pus was found high up close to the edge of the twelfth 
rib, beneath the quadratus muscle. This was drawn aside, and the cavity was opened 
by Hilton-Koser's method. About an ounce and a half of odorless pus escaped, and 
digital exploration showed that it had been contained in a small, smooth-walled cavity. 
Drainage and antiseptic dressings being applied, the wound was irrigated and dressed 
daily; later on, at longer intervals. The patient was discharged cured September 6th. 

i. Anal Abscess. Fistula in Ano. — The anus, the final strait through 
which all excrementitions matter must pass, is subject to a great number of 
traumatisms from within and without. Foreign bodies, such as pits and 
kernels, chicken- and fish-bones, are frequently caught by, and imbedded in 
the mucous lining of the sphincter muscle. The rough introduction of 
syringe-points for the application of enemata, scratching and manipulation 
of itching and bleeding piles, the surgeon's digital exploration, sodomy, 
and the forcible expulsion of massive faeces, lead to superficial injuries of the 
mucous membrane and outer skin of the anal region. Persons whose hands 
and faces are habitually unclean do not scruple much about the untidy con- 
dition of their breech. And the faeces of even the most cleanly swarm with 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 255 

bacteria. In view of these facts, the frequency of ulcerative and suppurative 
affections of the anal region must appear very natural. 

Anal abscesses are generally located in the ischio-rectal fossa. This is 
the space limited by the rectum on the mesial side, the tuberosity of the 
ischium externally, the levator ani muscle above, the superficial perineal 
fascia below. It is very rare to meet with a periproctitic abscess situated 
above the levator ani. If such is the case, we have to deal with graver 
affections involving the pelvic organs, or with abscess from ulceration due 
to stercoral impaction caused by cancerous rectal stricture. 

Case. — Mary Steiger, aged fifty-nine. Far-gone cancer of rectum. Stenosis very 
tight, causing great difficulty at defecation. A profuse purulent discharge from the 
anus indicated the presence of ulcers or an abscess above the stricture. Exploration 
of the rectum above the cancer was absolutely impossible. High temperatures were 
noted. August 13, 1885. — Anterior colotomy in the German Hospital. No diminution 
of fever after the operation. August 16th. — Wound healed by the first intention. 
August 17th. — Patient delirious. Discharge from anus very profuse. August 18th. — 
Patient died with symptoms of septicaemia. Post mortem revealed firm union of 
colotomy wound throughout and a normal peritoneal cavity. In the sacral excavation, 
just above the massive ulcerated cancer, a very large fetid abscess was found. 

The presence of anal abscess is the source of intense suffering to the 
patient, and ascertaining of its precise location by the surgeon is generally 
not very difficult. By digital examination of the rectum a resistant, hard, 
or sometimes fluctuating swelling can be felt protruding laterally into the 
gut. Early incision is very urgently indicated, as upon it may depend the 
avoidance of the formation of fistula, or of a dissecting or "horse-shoe 
abscess," which may detach almost the entire lower gut from the adjacent 
connective tissue. This latter form of abscess is especially to be feared, as 
its healing is extremely difficult. But, where fluctuation is absent, success- 
ful evacuation of a deep-seated periproctitic abscess is no easy matter. 

After a purge and enema, the patient should be anaesthetized and 
brought into Bozeman's or the lithotomy position. (See Fig. 122, page 154.) 
A sponge tied to a piece of stout silk is pushed well into the rectum, and 
the lower end of the gut and the anal region are flushed with corrosive-sub- 
limate lotion. Then the index-finger is introduced and placed against the 
swollen side for fixation. A stout exploring needle is thrust through the 
skin into the swelling repeatedly from without until it strikes the suppurat- 
ing focus. It is left in situ for a guide, and an ample incision is gradually 
extended until the abscess is freely opened. The wound should have the 
shape of a funnel, its apex being in the abscess. This will secure natural 
drainage. The wound is loosely packed with iodoformed gauze, and the 
anus is inclosed in a moist dressing, which should be renewed every day. 
Daily irrigation, or in very irritable patients a sitz bath, will have to main- 
tain cleanliness. 

In cases where extensive detachment of the rectum or perforation into 
the gut has taken place, simple incision will be insufficient, and division of 
the intervening bridge will be necessary. 



256 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

By spontaneous evacuation outward, external incomplete fistula will be 
established. Some of these cases can still be cured by a free bloody dilata- 
tion of their orifice, and a careful antiseptic treatment as above indicated. 
But most of them are complete fistulm, the inner openings of which can not 
be found on account of their minuteness. 

Cases of incomplete internal and of complete fistula should be cut. 

In incomplete inner fistula a Sims' vaginal speculum is used for exposing 
the entrance to the sinus. A bent probe and alongside of this a bent 
grooved director is introduced into it, and is pushed well outward toward 
the skin, which is incised over the point of the instrument. After this the 
intervening bridge is divided. 

Complete anal fistula, especially where several sinuses exist, should 
always be carefully explored before the incision is made, as otherwise 
pockets and branching sinuses may be overlooked. A silver probe should 
be introduced into each sinus and left in situ until its turn for cutting 
should come. A grooved director is carried into the gut along one of the 
probes, is caught up by the tip of the left index-finger, and turned out of 
the anus. The bridge of tissue taken up by it is then divided. The edges 
of the cut are well drawn apart by four-pronged sharp hooks, in order to 
facilitate securing and tying of spurting vessels. The next sinus is taken 
up after the first, and every nook and recess is carefully examined and split 
open until natural drainage is secured everywhere. Free irrigation of the 
wound should be employed during the whole process. When haemorrhage 
is properly attended to, all the old granulations should be forcibly scraped 
away with the sharp spoon, and the wound should be packed with narrow 
strips of iodoformed gauze. After this the sponge is withdrawn from the 
rectum, and a moist dressing is applied and held in place by a T-bandage. 
(Fig. 126, page 157.) 

Note. — When the internal orifice can not be found, or a burrow extends upward beyond 
it, the grooved director should be inserted as high up as the cavity or sinus permits, and thence 
should be thrust through the mucous membrane into the gut. 

The length of time required for the cure of fistula in ano will depend 
on the extent and form of the wound made by the surgeon. In simple 
cases a fortnight or three weeks will suffice ; complicated ones may need 
months. In favorable cases, that is, where the fistula is straight and single, 
cure can be very much hastened by excision and suture of the entire fistu- 
lous track. The restitution of the parts to their normal condition will at 
the same time insure against incontinence. The callous lining of the sinus 
is carefully excised with forceps and curved scissors, and the remaining 
wound is united by several tiers of buried catgut sutures, the ends of which 
should be clipped off short. The uppermost tier of sutures should not 
inclose the mucous membrane, but the curved needle should be introduced 
close to its edge on one side, and brought out in the same manner on the 
other side. Thus inversion of the mucous lining will be avoided, and the 
stitches, being buried under the overlapping edges of the mucous mem- 
brane, will be protected from infection by intestinal contents. The exter- 



DIAGNOSIS AND TREATMENT OF PHLEGMON. 



257 




Fig. 188.— Operation of fistula in ano. Grooved director 
passed through fistula and brought out of the anus, 
from which is seen depending a thread holding sponge 
pushed well up the rectum. (Simon Schulhof's case.) 



nal, that is, cutaneous, part of the wound can be closed by silver-wire stitches. 
Free irrigation of the wound during the entire time of the operation is indis- 
pensable to preserve asepsis. 
Iodoform is dusted over and 
rubbed into the line of union, 
and the anus is inclosed in a 
moist dressing. 

Case. — Simon Schulhof, labor- 
er, aged forty-three and a half, re- 
ceived, during the Austro-Prus- 
sian war of 1866, a bayonet wound 
near the anus. Suppuration and 
the formation of fistula followed, 
and resisted three operations which 
had been performed since that 
time. February 5, 1887. — Under 
ether, the fistula was slit up at 
the German Hospital. Its exter- 
nal orifice was nearly two inches 
from the anal margin; the inter- 
nal one, one inch and a half up 
the rectum. The direction of the 
track was straight, and no lateral 
sinuses were present. The en- 
tire cicatricial lining of the fistula was excised with forceps and curved scissors, and 
the internal defect was united with three tiers of fine catgut sutures. The external 

wound was brought together with two silver- 
wire stitches. Into the outer angle of the 
skin- wound a short piece of slender rubber 
drainage-tube was placed. A pledget of iodo- 
formed gauze was placed into the anus, and 
the wound was dressed with gauze and a T- 
bandage. No reaction followed. In the after- 
noon of February 7th, four ounces of sweet- 
oil were injected into the gut, and the oil- 
soaked gauze was withdrawn from the anus. 
An hour after this a large enema of soap- 
water was administered, and brought away a 
liquid stool. The next morning a saline laxa- 
tive was given, and was continued every day, 
each stool being followed by irrigation of 
the anus to free it from excrementitious mat- 
ter. February 10th.— The silver stitches and 
rubber tube were removed. The accompany- 
ing cut shows the condition of the wound on 
the tenth day after the operation. The action 
of the sphincter was perfect. (Fig. 189.) 

Regarding the management of the first and subsequent evacuation of 
the bowels, the reader is referred to the chapter on haemorrhoids (page 156). 




Fig. 189. — Eesult after excision and suture 
of fistula in ano. (Simon Schulhof's case. ) 



258 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

In very extensive cases of fistula of long standing, where the inner 
orifice is very high up, say two inches or more above the anal opening, 
and where avoidance of haemorrhage is rendered imperative on account of 
the anaemic condition of the patient, the elastic ligature can he successfully 
substituted for the knife. The grooved director is carried through the 
sinus into the gut as usual, and, if possible, its point is turned out of the 
anus. Where this is impossible, a slender, soft, silver probe is armed with 
a fillet of stout silk, to the end of which a piece of elastic ligature or a 
small-sized drainage-tube (the size used on infants' feeding-bottles is very 
good) is firmly tied. The silver probe is next carried along the grooved 
director into the gut, its point is caught up by the tip of the left index- 
finger, and being bent upon itself is grasped with a stout pair of dressing- 
forceps and withdrawn. Thus the silk thread will be placed into the sinus, 
and with a seesaw motion will clear a way for the elastic ligature, which is 
drawn through after it. The ends of the elastic ligature, being firmly held 
each by one hand, are well drawn upon, and become tense and attenuated. 
Thus stretched, they are crossed over each other in front of the anus, and 
are secured in this position by a ligature of silk. As soon as the rubber is 
released, it crowds up against the silk ligature, and is held securely in 
place. Its ends are trimmed off short. 

The elastic ligature is in every way preferable to the silken one, as it 
cuts through more rapidly, and does not require retightening. 

Where the external orifice of the fistula is not close to the anal opening, 
the intervening skin must be cut through with the knife before the tight- 
ening of the ligature, to avoid the intense pain due to strangulation of the 
cutaneous nerves. 

Incontinence is occasionally produced by fistula operations requiring 
single or multiple division of the entire sphincter. In these cases a sec- 
ondary proctoplasty offers fair chances of partial or complete recovery of 
the function of the muscle. 

Case. — Barto Weil, brewer, aged fifty-six, suffered from distressing incontinence 
of the rectum, caused by four extensive fistula operations, performed successively for 
the horseshoe variety of this affection. At the last operation the author applied two 
elastic ligatures, one of which reached three inches, the other three inches and a half 
up the rectum. An irregular gaping aperture remained, from which rectal mucous 
memhrane protruded in a number of folds. One granulating oblong surface was still 
extending nearly two inches into the gut. May 28, 1886. — Under ether, the entire 
irregular cicatrix was excised, and the remaining flaps of mucous membrane, together 
with the lower end of the uncut rectum, were dissected up and drawn well down. 
By a large number of catgut stitches the cylindrical shape of the anal opening was 
re-established, and the new anal ring was sewed to the external skin. A triangular 
defect remaining on the right of the anus was covered by a skin-flap shaped out of a 
shrunken integumental caruncle found posteriorly. Two small drainage-tubes were 
placed well up between rectum and ischio-rectal connective tissue. Primary union 
followed through the greater exteDt of the wound, and ultimately continence was 
fairly re-established. The patient was discharged cured July 24, 1886. 



EEYSIPELAS AND PSEUDO-ERYSIPELAS. 



259 



CHAPTER VII. 



ERYSIPELAS AND PSEUD 0- ERYSIPELAS. 



The rules of aseptic management described in former chapters are the 
best safeguard against the infection of operative wounds by the specific coc- 
cus of erysipelas. (Fig. 131, page 169 ; Plate II, Figs. 5 and 6 ; and Fig. 
190.) The author has observed only four cases of wound erysipelas in ten 
years both of public and private practice. In one of these, in 1879, ery- 
sipelatous infection was transmitted from a case of so-called idiopathic 
erysipelas of the face to the genitals of a woman in childbirth by the author's 
hands, in spite of ordinary measures of cleanliness. Had disinfection been 
applied after the usual 
washing of the hands, the 
patient might have been 
living to this day. 

The other case of ery- 
sipelas was observed after 
the first visit of a new 
member of the house- 
staff of Mount Sinai Hos- 
pital, at which the dress- 
ing of a nearly healed 
wound was changed by 
the young physician in 
question. The case was 
cured. 

Note. — The time of changes 
in the house-staff of the surgical 
wards of hospitals is generally 
signalized by unexpected suppu- 
rations. The author has learned Yia. 190.- 
to dread the loss of a good and 
well-trained assistant, who is 

occasionally replaced by an inefficient, uncleanly, and indolent personage. Disaster can be 
averted at such times only by increased vigilance and redoubled diligence on the part of the 
visiting surgeon in personally supervising the details of the service. 

The third case was mentioned in the paragraph on perityphlitic abscess. 

The last case of erysipelas within the author's experience was that of a 
young woman suffering from caseous cervical glands. For cosmetic reasons 
the glandular swellings were punctured with a narrow bistoury, and, a small 
curette being introduced into the broken-down center of the gland, its case- 
ous contents were scraped out. The small wounds were drained with cat- 
gut. Erysipelas, commencing from one of the punctures, set in, but ended 













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4§i ^*' 




JiSEL > ■' :' f - 




i L :§ # ■ 





Section of erysipelatous skin of head 
diameters;. (Koch.) 



TOO 



260 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

in cure. Undoubtedly either the bistoury or, more likely, the sharp spoon 
was the carrier of the virus. 

There is not one among the many topical remedies recommended by the 
writers for erysipelas that is pre-eminent in limiting or stopping the affec- 
tion. The author's local treatment consists in moist antiseptic dressings 
inclosing the affected parts, with a general supporting treatment by proper 
nourishment and stimulants. The much-praised specific effect of the tinct- 
ure of iron is, to say the least, very problematic. 

Note. — Lately Kraske has published a series of cases in which multiple scarification and 
puncture of the affected parts, especially along the line of the spread of the disease, has led to 
prompt cure. The little operation is followed by the application of a moist antiseptic dressing. 
As the principle of this mode of therapy is rational, consisting in depletion and disinfection, it 
would deserve extended trial. 

An unmixed infection by the coccus of erysipelas will never cause ab- 
scesses. Whenever abscesses form with erysipelas, we have to deal with a 
mixed infection, namely, by the coccus of erysipelas, and by one or another 
of the pus-generating cocci. 

Phlegmon and erysipelas also represent a mixed form of infection, but 
this combination is rare. What is generally called phlegmonous erysipelas 
is commonly no erysipelas at all. It is a phlegmon produced by the pyo- 
genic chain-coccus, the spread of which along the lymphatics resembles that 
of true erysipelas. 

Pseudo-erysipelas is an erysipelatoid skin affection of the fingers and 
hand that resembles true erysipelas in most of its morphological features. 
But it presents this important clinical difference, that it never is accompa- 
nied by fever. The affection is very tractable, as the application of a three- 
per-cent carbolic lotion for a few hours will generally consummate a cure. 
Its cause is a specific coccus described by Rosenbach. 



PAET III. 



TUBERCULOSIS : 
ITS ASEPTIC AND ANTISEPTIC TREATMENT. 



35 



CHAPTER VIII. 



NATURAL HISTORY AND TREATMENT OF TUBERCULOSIS. 



I. ETIOLOGY OF TUBERCULOSIS. 



Koch's discovery of the specific bacillus of tuberculosis has brought 
about a recoustructiou of pathological classification and nomenclature that 
commends itself by clearness and simplicity. Miliary tuberculosis of the 
lungs and other internal organs, scrofulous affections of the lymphatic 
glands, the various forms of surgical tuberculosis, as, for instance, white 
swelling and caries, finally the several forms of lupus, are manifestations of 
one and the same mor- 
bid process — namely, of 
cellular decay caused by 
the deleterious influence 
of a vegetable parasite, 
Koch's tubercle bacillus. 

The identity of this 
bacillus can be indubi- 
tably established by cer- 
tain modes of staining. 
No other known micro- 
organism will be affect- 
ed by Koch's or Ehr- 
lich's mode of staining 
like the tubercle bacil- 
lus. It appears under 
the microscope as a blue, 
elongated body of the 
length of half a red 

blood-corpuscle, and is found occupying alone or in company with other 
individuals a giant cell generally located in the center of a fresh tubercle. 
(Figs. 191, 192, and 193.) 

The distribution of the tubercle bacillus is very unequal. It is found in 
large numbers where the invasion of the disease is recent, or where it is 
rapidly extending. It is very scanty in chronic affections like glandular 
scrofulosis or lupus. 




Fig. 191. — Miliary tubercles of lung, with central caseation 
'(50 diameters). (Koch.) 



264 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




The peculiarity of the tubercle bacillus is to incorporate itself with a 
white blood -corpuscle, and to influence it in such a manner as to convert 
it into a lymphoid cell of somewhat large proportions. This cell becomes 

sessile in some part of the body. 
After a while new lymphoid cells 
appear in the vicinity of the first 
cell, which by this time will have 
grown to the proportions of a mul- 
tinuclear giant cell, containing a 
number of bacilli (Fig. 195). As 
the infection spreads along the pe- 
riphery, peculiar changes are seen 
to occur in the center of the nodule 
composed of lymphoid cells. The 
nuclei of the lymphoid and giant 
cells lose their staining capacity and 
coagulate into a granular mass. The 
bacilli contained within them dis- 
appear, leaving behind, however, a 
crop of invisible spores that, trans- 
ferred to a suitable soil, will readily 
produce a new growth of bacilli. 
With the formation of this co- 
agulated mass of decayed cell-elements the process of caseation is estab- 
lished. The presence of this mass of necrosed tissue acts as an irritant 
upon the capillaries of the vicinity, and a wall of new-formed granulation 
tissue is thrown up around the focus. Should the infection of the neighbor- 
ing tissues occur before the protecting wall of new-formed granulation tissue 
is completed, exten- 
sive caseous infil- 
tration will be the 
result. 

The barrier of 
new-formed granu- 
lations is also liable, 
here and there, to 
invasion by bacilli, 
and therefore casea- 
tion will generally 
extend in a rather 
irregular manner. 

An increased ex- 
udation of blood- 
and white 



Fig. 192. — Part of one tubercle from foregoing 
illustration. Bacilli interspersed between nu- 
clei (700 diameters). (Koch.) 




Fig. 193.- 



-Part of miliary tubercle from a case of basilar menin- 
gitis (700 diameters). (Koch.) 



serum 

blood-corpuscles will finally bring about emulsification of the cheesy focus, 

which then represents the beginning of a cold abscess. 



ETIOLOGY OF TUBERCULOSIS. 



265 




Fig. 194. — Giant cell containing bacilli taken from 
miliary tubercle (TOO diameters). (Koch.) 



There is no organ of the human body that is exempt from the possibility 
of tuberculosis. 

The predisposition to infection by the ubiquitous spores of the bacillus 
of tuberculosis is manifestly increased by any kind of deterioration of local 
or general bodily vigor. Mal- 
nutrition, whether due to an at- 
tack of measles or the whooping- 
cough, or to a chronic catarrh 
of the infantile gut caused by 
improper nursing, or to long- 
continued suppuration from an 
osteomyelitic sequestrum, is, as 
a matter of actual observation, 
very often followed by local and 
general tuberculosis. 

The most common tvay of in- 
fection is undoubtedly that by 
the lungs. Catarrhal affections 
of the bronchial mucous mem- 
brane, regularly accompanied by superficial denudations of the epithelium, 
serve as portals for the entrance and implantation of the spores of the bacil- 
lus. And, as the deterioration of the general state of health after measles is 
combined with a catarrhal condition of the bronchi, infantile tuberculosis is 

most commonly acquired after this 
eruptive disease. For unknown 
reasons the pulmonary tissues of 
children do rarely become involved 
in serious tubercular trouble ; but 
the virus is promptly transmitted 
to the bronchial lymphatic glands 
(Fig. 195), which undergo casea- 
tion, and, on account of their close 
vicinity to the thoracic duct and 
various vessels, serve as a depot for 
further distribution. 

We owe to Ponfick proof of the 
fact that perforation of a caseous 
focus into the thoracic duct may 
cause a more or less general dissemination of tuberculosis. Koch himself 
has demonstrated another manner of distribution in the involvement and 
caseation of arterial walls. But the most common way of systemic tubercu- 
lar infection was found by Weigert in the decay of the walls and perforation 
into the lumen of veins, which generally hold very intimate anatomical rela- 
tions to caseous glandular tumors. 

Entrance of small quantities of tubercular virus into the general circu- 
lation bv the ways above indicated will lead to local tubercular affections of 




Fig. 195. —Giant cell, with radial arrangement 
of bacilli, from a caseous bronchial " gland 
(700 diameters). (Koch.) 



266 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



various organs, as, for instance, the bones, testicle, or joints. Massive in- 
vasion, on the other hand, will cause fatal general miliary tuberculosis. 

Tubercular matter carried along by the circulating blood is most apt to 
be arrested and to become sessile in the vicinity of the terminal arteries. 
The views expressed in the chapter on the localization of acute infectious 
osteomyelitis seem to be applicable also to the localization of the tubercular 
process. (Page 195.) 

Another rarer manner of tubercular infection is that by lesions of the 
skin. A Jewish circumciser suffering from pulmonary and faucial tuber- 
culosis, communi- 
cated the disease 
to twelve infants 
by sucking their 
preputial wounds. 
This used to be 
the accepted man- 
ner of stanching 
haemorrhage after 
ritual circumcision 
in former times. 

Note.— In 1879 the 
author was the victim of 
local tuberculosis of the 
pulp of the thumb, con- 
tracted by the infection 
of a small cut received 
during the amputation of 
a thigh for tuberculosis 
of the knee-joint, com- 
plicated with large tubercular abscesses of the thigh and of the medulla of the femur. A case- 
ating elevated ulcer of the thumb developed and persisted for six weeks. The complaint healed 
after the final detachment and expulsion of two caseous plugs. 

The dissemination of tubercular matter during surgical operations, done 
for the cure of the complaint, was first pointed out by Koenig. 

It is well known that death by general tuberculosis is seen to follow 
exsection of the hip-joint with especial frequency. Upon this circum- 
stance is based the statistically proved fact that the expectant or rather 
non-operative treatment of this complaint yields better results than an 
active operative therapy. 

Note. — These facts find a ready explanation in the circumstances under which most early 
exsections of the hip-joint are carried out. The depth of the diseased joint ; the difficulty of 
liberating the head of the femur, still held down firmly by undestroyed ligaments; the desire of 
operating subperiosteally, that is, with the employment of a good deal of blunt force ; the forci- 
ble manipulations in distending the edges of the deep wound by retractors — all serve to propel 
any freed caseous matter into the cut orifices of veins and lymphatics. The result is that, by 
the time the local tuberculosis combated by the surgeon is healed, the patient succumbs to 
meningeal or pulmonary tuberculosis, probably chargeable to operative interference. 



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"^%2S§»*a. 





Fig. 196. 



-Giant cell containing one bacillus from Fig. 191 
(700. diameters). (Koch.) 



TREATMENT OF TUBERCULOSIS. 267 



n. COMPLICATION OF TUBERCULOSIS WITH PYOGENIC OR 
SUPPURATIVE INFECTION. 

Tubercular decay of tissues by caseation is a generally slow process, as 
long as the affection remains subcutaneous — that is, occluded from access 
of air with its pyogenic organisms. But let a tubercular focus of the lung 
perforate into a bronchus, or let a group of caseous glands, or a cold abscess 
communicating with a distant focus of the spine or some joint, be opened 
without aseptic precautions, and the affection will have at once entered 
upon a new and more destructive phase. The formerly thin, flocculent dis- 
charge will assume a more purulent character, the production of pus will 
become prodigious, more or less fever will set in, and the symptoms of a 
rapidly progressive local destruction of tissue accompanied by hectic, will 
become more and more pronounced. 

A new infection was thus implanted upon a soil already impoverished by 
ill-nutrition and preyed upon by a destructive parasite. To the slow decay 
of tuberculosis, the rapidly disorganizing forces of purulent infection were 
added. The seriousness of this contingency was justly comprehended by 
old-time surgeons, who abhorred meddling with a cold abscess or any covert 
strumous affection. Incision of a cold abscess then meant purulent infection 
of the cavity, extending to the often inaccessible primary focus of the dis- 
ease, hectic fever, and rapid emaciation and decay of the patient- 
Just appreciation of these remarks will at once impress upon the mind 
the great necessity of aseptic measures in our operative dealings with 
tubercular affections. 



IH. TREATMENT OF TUBERCULOSIS. 

General Principles. 

Considering the fact that about seventy per cent of all deaths are directly 
or indirectly caused by tuberculosis of various organs, principally consump- 
tion, and that the management of the infectious sputa of consumptives is 
careless in the extreme, it must be admitted that efforts at prevention offer 
no great hope of success. The sputa containing active bacilli or their spores 
are ejected on the ground or floor, dry there, and are converted into dust, 
which will penetrate everywhere and will cover everything with its deadly 
burden. The tent of the Indian and the palace of the millionaire are pene- 
trated alike by dust containing dried and pulverized sputa of consumptives, 
and millions of spores of pyogenic cocci, derived from suppurating wounds, 
the discharges of which are carelessly thrown every day upon the ground, 
to be whirled up from there by draughts of air. 

A more promising line of prevention can be cultivated in the proper 
nourishment and regime of the individual. The better the general con- 
dition of health, the fuller and more abundant the blood supply of this or 
that organ, the less the chance of its becoming the seat of tuberculosis. Or, 



268 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



if passing conditions of anaemia caused by illness or loss of blood have led 
to the establishment of a tubercular focus, raising of the general health by 
proper diet and exercise in the pure air of the sea or of high mountains, will 
check and often wholly eliminate the ravages of the disease. A generous 
diet, with plenty of exercise in the open air, is the best preventive and sys- 
temic curative of tuberculosis. To the observance of scrupulous cleanliness 
in the household and in our personal habits must also be acceded a great 
protective, and in some measure a curative influence. 

Local Treatment of Tuberculosis. 

Knowledge of the true nature of the various forms of surgical tubercu- 
losis has led to a clear understanding of the principles governing its suc- 
cessful treatment. Since we do not possess any therapeutic agent capable 
of destroying the bacillus of tuberculosis in situ, without interfering with 
the tissues that harbor it, chemical and mechanical influences must be 
brought to bear upon the tuberculous focus, with the object of destroying 
and removing all cell elements infested with the specific virus. In short, 
the modern treatment of local tuberculosis is identical with that accepted 
for the cure of malignant new growths ; it consists in a more or less com- 
plete removal of the affected tissues or organs by caustics, the knife, or the 
gouge, under aseptic precautions. 

1. Cutaneous Tuberculosis. Lupus (Fig. 197). — Various chemical caus- 
tics, the actual cautery, and excision are known to effect a cure of cuta- 
neous tuberculosis. In- 







ternal medication has no 
effect upon it. The most 
destructive forms of lupus 
are those representing a 
complication of tubercu- 
losis with pyogenic infec- 
tion — as, for instance, lu- 
pus exedens. The miliary 
nodes nearest the surface 
caseate, break down, and 
perforate, and the way 
is open for the entrance 
of pus-generating cocci. 
Lupus of the face should 
be treated by caustics 
and scooping. The more 
radical treatment by ex- 
cision is not to be commended in facial lupus on account of the disfigure- 
ment it is apt to cause. Relapses are frequent, and should be attacked over 
and over again as soon as they appear. Lupus of non-exposed parts of the 
skin should be exsected. The following case demonstrates the identity of 
lupus and tuberculosis : 



Ml 



197. — Section of lupous skin. Giant cell containing 
one bacillus (700 diameters). (Koch.) 



TEEATMENT OF TUBERCULOSIS. 269 

Case. — Otto Krirn, aged five. Lupus exedens over the left external malleolus of the 
size of a silver dollar. The affection existed for nearly three years ; about a year ago 
glandular swelling appeared in Scarpa's triangle of the left side and in the correspond- 
ing groin. Extensive scrofulous ulceration of the skin followed, and caseous glands 
lay exposed in the bottom of the inguinal wound. February 4, 1887. — Extirpation of 
the lupous patch and of the glandular masses from Scarpa's triangle and above Pou- 
part's ligament. The peritonasum was exposed, and had to be stripped up to the ex- 
ternal iliac vessels to permit complete removal of the glands. Primary union of the 
wounds about Poupart's ligament. The malleolar wound healed under a Schede dress- 
ing. February 27th. — Patient discharged cured. 

2. Tuberculosis of the Mucous Membranes. — Scrofulous rhinitis, or 
coryza, is a very rebellious affection of the nasal mucous membrane. It is 
easily recognized by the chronic swelling of the mucous covering of the 
nasal cavity, the swollen upper lip, open mouth, hard hearing, and noisy 
breathiug. Its surgical importance lies in its tendency to produce an early 
affection of the cervical lymphatic glands — scrofula. Ulcerative destruc- 
tion of the mucous covering of the nasal bones opens the way for the ingress 
of pyogenic organisms, which bring about frequently more or less extensive 
necrosis. An intensely fetid odor makes the presence of these patients in- 
tolerable. Termination of this condition is best accomplished by removal 
of the necrosed bones in Eose's dependent position of the head. (Fig. 170, 
page 213.) The sequestra are easily dislodged by the sharp spoon. The 
haemorrhage is at first rather profuse, but soon subsides on irrigation with 
ice-water. Daily irrigation of the nasal cavity with a mild solution of cor- 
rosive sublimate (1 : 5,000) should be used until discharges cease to appear. 

Tuberculosis of the anal mucous membrane is a most frequent cause of 
tuberculous fistula in a no. Simple slitting up of these fistulous tracks, lined 
with caseous granulations, and often dotted with miliary tubercle, will not 
accomplish their cure. Every nook and recess of the fistula must be carefully 
explored, and all caseous or granular matter must be removed by vigorous 
scooping and, if need be, excision. A thorough -going operation will always 
be followed by improvement, and in not too extensive cases by local cure. 

Tuberculosis of the urethra and bladder is a most distressing complaint, 
and is hardly amenable to any form of treatment. Sedatives and, in cases 
where the affection of the neck of the bladder renders life intolerable on 
account of the unceasing painful strangury, median perineal cystotomy are 
indicated. 

A common sequel of urethral tuberculosis is caseous epididymitis and 
orchitis. Testicular tuberculosis caused by urethral disease is generally 
bilateral. Single tuberculosis of the testicle, on the other band, is gener- 
ally of embolic origin. Its sovereign remedy is castration. 

3. Tuberculosis of Lymphatic Glands, or Scrofula (Fig. 198).— Caseous 
chronic lymphadenitis is one of the most common affections of childhood 
and adolescence. Its foundations are generally laid by chronic affections of 
the oral, nasal, and aural mucous membranes, by tubercular affections of the 
cervical vertebrae, and by eczema of the face and scalp. The incipient stages 

36 



270 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



of the trouble can sometimes be controlled by timely attention to the causal 
disorders, an appropriate general treatment, and the local application of 
one or another preparation containing iodine in the shape of an ointment. 

As soon as caseation has been well established, general and topical treat- 
ment of the milder sort will be of no avail. 

The modern therapy of scrofulous lymphatic glands is dominated by 
the idea that they are not only the cause of present discomfort and suf- 
fering to the patient, but especially that within them is contained the seed 
for renewed infection, which by its dissemination through the circulation 
may cause other local affections or a fatal general malady. The close ana- 
tomical relation of most lymphatic glands to important venous trunks or 
their immediate affluents renders their early attachment by inflammatory 
deposit very easy. Cheesy degeneration will ultimately reach the wall 

of the vein itself, and a wide dis- 
semination of the tubercular virus 
through the circulation is the result. 
The surgical therapy of cheesy 
lymphadenitis will have to be varied 
according to the stage of the dis- 
ease, the chief object being always 
thorough removal or destruction of 
all infected tissues. 

Where there is central caseation 
only, and no fistula, nor an appre- 
ciable abscess, bodily excision of 
the glandular masses is most appro- 
priate. The neck being the most 
common seat of the trouble, a few 
words may be said regarding the 
detail of the operative treatment of 
scrofulous cervical glands. 

The incision should be ample, 
and, if the tumors be very exten- 
sive, the formation of a flap is advisable. The capsule of the uppermost 
gland being split, the glandular body is shelled out of its nest. This is 
much facilitated by an assistant's holding aside the detached capsule with 
a small, sharp retractor while the surgeon suitably changes the position of 
the mass by turning it one way, then another, until all the looser attach- 
ments are divided. Great care must be exercised herein not to lacerate or 
crush the brittle substance of the gland. 

Each gland has its afferent and efferent vessels, and these form a sort of 
pedicle, which must be tied off before it is cut. 

In cases of very extensive involvement of the cervical glands situated 
both in the vascular and intermuscular interspaces (see page 208), it is very 
advisable to cut the ster no-mast oid muscle across and in two. The spinal 
accessory nerve will be found near its posterior margin, and should be saved. 



k£%j@ 2^ ^ M JS^^r 




B 


". '?■ 


" m ^ ^BL 


, ».. i 


W--. ■ •/; s ;*■". 






, -j;.-' 


h' P. ,j ^. 









Fig. 198. — Giant cell containing one bacillus 
from a scrofulous gland of the neck (700 
diameters). (Koch.) 



TREATMENT OF TUBERCULOSIS. 271 

The stumps of the divided sterno-mastoid muscle are raised from their 
mesial attachments, and. one is turned up. the other is turned down. The 
otherwise difficult and even dangerous dissection of the glands from the 
vicinity of the large vessels is made much easier by the free exposure afforded 
by cutting the sterno-mastoid. which should be reunited by a number of 
catgut stitches after the completion of the exsection. 

The manner of placing the drainage-tubes, the suture, and dressings, 
do not differ from the usual arrangement. Before closing the wound, a 
thorough mopping out with a strong solution (1 : 500) of corrosive subli- 
mate is necessary, to make sure of destroying all spores of tubercle bacilli 
that may have escaped with cheesy matter from accidentally injured glands. 

When dealing with progressed -central cheesy abscesses of the cervical 
glands, a different course must be pursued. Incision of each abscess, fol- 
lowed by a thorough scooping away of all granulations and broken-down 
glandular tissue, is the proper treatment. The sharp spoon can and should 
be used rather vigorously, and no fear need be felt of injuring large vessels 
lying close by the walls of the abscesses, as there is a tough and thick wall of 
organized connective tissue interposed to protect them. A draiuage-tube is 
to be inserted into each cavity. 

Gaseous abscesses that have perforated spontaneously, or have been 
opened inadequately, generally lead to tubercular infection of the subcuta- 
neous tissue in the vicinity of the aperture. More or less extensive under- 
mining and bluish discoloration of the shin are the consequence. The un- 
dermined, irregular edges show very little tendency to heal : they become 
inverted, and if healed, present an ill-shapen, uneven scar. 

To aid and hasten the inadequate efforts of Nature, it is necessary to 
extirpate or gouge out the glandular bodies, to trim away all the under- 
mined portions of skin with the curved scissors, paying no regard to the ex- 
tent of the resulting wound. However large the denudation, it will heal 
rapidly and kindly under Schede's dressing, and. on account of the mo- 
bility and abundance of the cervical integument, the resulting cicatrix will 
be nearly linear in shape. 

Note. — Glandular, cheesy abscesses on the necks of grown girls can be healed, without 
leaving a conspicuous scar, by repeated punctures with a stout aspirating-needle. The contents 
of the abscess being removed by aspiration, corrosive-sublimate lotion is injected through the 
cannula, and is again withdrawn. This is repeated until the lotion returns clear and limpid, 
when the cannula is taken out. The puncture-hole is protected by a drop of iodofornied collo- 
dion. The process is repeated whenever the abscess refills, until the cavity becomes closed. 
The author has cured two cases in this manner. 

4. Tuberculosis of Tendinous Sheaths. — Weeping sinew or acute syno- 
vitis of the tendinous sheaths sometimes degenerates into a chronic affection 
of their synovial lining known under the name of proliferating hygroma. 
This rebellious affection is characterized by an elongated, fluctuating, 
irregular swelling of the carpal region. It is painless, but impedes the free 
use of the fingers. The swelling is due to a gelatinous thickening of the 
sheaths of the sinews. The tendons finally become adherent to the degen- 



272 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



erated mass, thus losing their free mobility. The sacs frequently contain 
some more or less discolored synovia, and sometimes a large number of rice- 
kernel-shaped concretions of fibrin. 




Fig. 199. — Group illustrating an exsection of tubercular tendinous sheaths of the palm. 



Topical applications make no impression upon this disorder, which can 
be cured only by free incision and methodical removal of the fibrinous 
bodies and the gelatinous sheaths by careful dissection in artificial anaemia. 
If the new growth extend underneath the transverse carpal ligament, and 
can not be got at otherwise, the ligament must be divided to permit 

thorough removal. The carpal ligament, 
fascia, and skin are united by several tiers of 
catgut sutures, a slit is left open at each end 
of the incision, and a compressive Schede's 
dressing is applied to the arm and hand, 
which should be placed on a volar splint ex- 
tending to the line of the metacarpophalan- 
geal joints. The patient is directed to active- 
ly move his fingers from the second day on, 
and thus to fashion grooves in the blood-clot 
filling the interior of the wound, which are 
to become new tendinous sheaths after the or- 
ganization of the clot. (Figs. 199 and 200.) 

Case I. — Samuel H., medical student, aged 

twenty-five. Tubercular gelatinous synovitis of all 

extensors of right hand and of flexors of left hand. 

December 30, 1886. — Extirpation of diseased sheaths 

of extensor tendons of right hand under Esmarch at 

Fig. 200.— Lines of incision on pal- Mount Sinai Hospital. January 12th. — First change 

mar and dorsal aspects of the hand of dressings . pr i marv UD ion. By January 20, 1887, 

for tendineal tuberculosis. (Case ° ' ' l J J J ' 

of Samuel H.) normal function re-established. January 27th. — 




TREATMENT OF TUBERCULOSIS. 273 

Similar treatment of flexor sheaths of left hand. Double ligature and division of super- 
ficial palmar arch ; division of carpal ligament. Suture of carpal ligament, fascia, and 
skin. February 13th. — First change of dressings; primary union. March loth. — 
Function of flexors normal. 

Case II. — Mina Scheller, aged twenty-five. Tuberculous synovitis of extensor ten- 
dons of both hands. March 26, 1886. — Operation of right hand at Mount Sinai Hos- 
pital. Primary union. April 6th. — Operation of left hand ; primary union. Janu- 
ary, 1887. — Function of both hands perfect. 

5. Tuberculosis of Bone. Caries. Cold Abscess.— Bone tuberculosis may 
appear in two ways : On one hand, it is either an independent affection of 
the shaft of a long bone, preferably in the vicinity of an epiphyseal line, or 
it is a deposit in the epiphysis itself, which by extension and perforation into 
the joint may cause tubercular arthritis ; on the other hand, tubercular in- 
volvement of the bone may be caused in tubercular arthritis of the synovial 
type by ulceration of the cartilage and direct infection of the exposed bone. 
No bone is wholly exempt from tuberculosis. The skull, the spine, the 
sternum, ribs and scapula, the pelvis, and the bones of the extremities are 
all liable to infection. 

The characteristic features of idiopathic bone tuberculosis are thicken- 
ing, the cheesy deposit, and, later on, ulcerative processes, against which 
the exuberant production of feeble and deciduous granulations conducts an 
uneven and unsuccessful struggle. In their turn the granulations also be- 
come infected and succumb to cheesy degeneration, and thus the process 
goes on interminably. Sequestra of large size, as in acute osteomyelitis, 
are never produced ; but the granulations contain smaller or larger rudi- 
ments of dead bone, and a good deal of bony grit is to be felt in the 
secretions. 

Cold abscesses represent the accumulated result of cheesy degeneration 
and emulsification. They travel by well-known routes, and the surgeon is 
generally able to conclude from the place of their external appearance where 
their source is to be looked for. 

Cold abscesses- contain an enormous mass of infectious matter. They 
are a drain upon the patient's health, and should be therefore always evacu- 
ated. Evacuation can be clone in several ivays, but it must under all circum- 
stances be done with strict aseptic precautions. The observance of asepticism 
is of especial importance where the focus of the disease is inaccessible, as 
for instance in Pott's disease. 

Note. — Evacuation by puncture with a well-disinfected trocar, with subsequent injection of 
a solution of five parts of iodoform in one hundred parts of ether, was proposed by Yerneuil, 
and has been found very effective by various surgeons, including the author. The injected ether 
evaporates in and distends the abscess cavity. Thus the iodoform enters every nook and corner 
of the irregular hollow, where it exerts the undeniably favorable influence of all iodides upon 
the tuberculous process. Undoubtedly, abscess cavities thus treated fill up much slower than 
after simple evacuation. Where the osteal process has reached its termination, they do not re- 
fill at all. From one to two ounces of the solution are to be used, and, after thorough disten- 
tion and gentle kneading for the sake of even distribution, the remnant should be permitted to 
escape through the cannula. 



274 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Cold abscesses situated in the vicinity of accessible foci, as, for instance, 
near the ribs, scapula, or about the extremities, can be treated much more 
radically. They should be incised to their full extent, and their pyogenic 
membrane and cheesy contents should be scraped away until bleeding, 
healthy tissue is reached. After this, the fistula leading from the abscess 
to the bone is searched, and the exact location of the diseased bone is ascer- 
tained. 

The treatment of the affection of the bone consists in free exposure and 
thorough removal of all portions that are manifestly in a state of ulceration 
or cheesy degeneration. The foci are made accessible by a free use of the 
chisel and mallet. The sharp spoon and gouge must clean out the last 
yestige of granulating or cheesy tissue, until the bone presents a healthy 
and fresh surface. Finally, the external wound is closed by suture, due 
regard being paid to drainage, and the parts are dressed aseptically. Thus 
primary union of the entire wound may be accomplished. 

The following example may serve as an illustration : 

Case. — Herman Mehle, barber, aged twenty-nine. Large cold abscess of inter- 
scapular space of dorsum, extending under the left scapula. January 6, 1885. — In- 
cision, evacuation, and scraping of the cavity. A sinus leading toward the transverse 
processes of the second and third thoracic vertebras was followed up by incision, and 
led to a number of small sequestra belonging to the heads of the second and third ribs. 
They were removed by gouging, and the abscess was closed by suture. Eelapse of the 
cicatrices required renewed scrapings. March 18th. — Patient was discharged cured. 

Revision — that is, exploration and supplementary removal of overlooked 
tuberculous masses by gouging and scraping — is a very necessary and per- 
fectly harmless measure, that should be employed within three or four 
weeks after the primary operation, in case the remaining sinuses show no 
tendency to heal. The appearance of exuberant ulcerating granulations 
about the orifices of the drainage-holes should be looked upon as an urgent 
indication for revision. Anaesthesia can be rarely dispensed with on these 
occasions. 

Tuberculous foci in the vicinity of a joint are a great menace to its sound- 
ness. Early detection and timely evacuation will have the character of a 
truly conservative step. The diagnosis of a single and central cheesy focus 
of a long bone is not easy to make ; but the lymphatic habit of the patient, 
the local swelling of the bone, with elevation of the local temperature and 
distinct spontaneous and pressure pain, may serve as valuable guides to its 
correct ascertainment. Slight stiffness of the joint nearest to the focus in 
the morning, with a hardly noticeable limp, which becomes more marked 
toward night, are significant warnings portending the gradual breaking 
down of the remnant of bone-tissue serving as a barrier against the inva- 
sion of the joint. 

Where cheesy foci are suspected in the vicinity of a joint, probatory in- 
cision and exploration are justified. 

In cases where the increasing swelling of the bone, a cold abscess, or the 
presence of sinuses with fever admit no doubt regarding the nature of the 



TREATMENT OF TUBERCULOSIS. 



275 



trouble, free incision and exposure by chisel and mallet must be practiced, 
followed by a painstaking removal of all degenerated tissues, sequestra, and 
cheesy deposits. The subsequent treatment of these wounds is identical 
with that advised after necrotomy for osteomyelitic sequestra. 
6. Tuberculosis of Joints. White Swelling : 





,c5* #; 




f|| 


- * d m J*' 

J* 5 ' x .,.ar ,^f? 


■8 " : ' 




®% 







General Part. 

Typical tuberculous arthritis, caused by perforation of an epiphyseal 
cheesy focus into the joint, or by an independent infection of the synovial 
membrane from a distant focus (bronchial glands) by way of the general 
circulation, is popularly known as white swelling. Mild cases of children, 
treated by an invigorating regimen 
and proper orthopedic measures, 
will yield very good results with- 
out serious operative interference. 

Even when "starting pains " 
indicate loss of the cartilaginous 
covering and caries of the joint 
surfaces, a cure by anchylosis or 
with the preservation of more or 
less mobility is possible. Small or 
great periarticular abscesses, in- 
cised and drained under aseptic 
cautelas, will heal kindly, and the 
ingrafting of the more intense pu- 
rulent infection upon tissues whose 
power of resistance has been low- 
ered by tuberculosis and disuse, 
will be avoided. A careless incis- 
ion, or a spontaneous perforation, on the other hand, is generally the start- 
ing-point of widespread destruction, caused by suppurative infection from 
without. Then, to conserve the limb or life of the patient, the diseased 
joint must often be sacrificed. 

a. Technique of Joint Exsection. — The technical rules to be ob- 
served in excising joints are governed by the following requirements : 

(a) Septic infection from without must be excluded by strict adherence 
to the rules of asepticism. If a local septic condition, due to purulent 
infection by uncleanly management of a cold abscess or sinus, be present, 
this has to be first eliminated by free incision and drainage of burrowing 
phlegmonous collections and by frequent irrigation. Only after the return 
of the temperature to nearly the normal standard is exsection permissible. 

Note. — Phlegmonous inflammation of a tuberculous joint is a much more serious trouble 
than that of a previous healthy joint. The cavities and sinuses preformed by the tuberculous 
process serve to disperse the new poison much more rapidly and widely than would otherwise 
be the case. Hence the formation of perforations and burrows up and downward between the 
muscles of the extremity occurs much sooner in tuberculosis than happens with a previously 



Fig. 201.— Giant cell containing two bacilli 
from fungoid granulations of the capsule 
of the hip-joint in morbus coxarius (700 
(Koch.; 



diameters). 



276 KULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

normal capsule. The typical mode of incision and drainage of the knee-joint, for instance, will be 
found insufficient in this contingency, and multiple perforation into the popliteal space will read- 
ily occur. Exsection of a knee-joint subject to the ravages of both tuberculosis and intense 
phlegmon will offer very slender chances of success, and amputation will have to be decided on. 

The preservation of asepticism is greatly promoted by almost continuous 
irrigation of the wound during the time of operation. Corrosive sublimate 
(1 : 1,000) can be fearlessly used for any length of time while Esmarch's con- 
strictor is in situ, as no absorption is thus possible (Woelner). In exsec- 
tions done without artificial ancemia, very iveak solutions of corrosive 
sublimate (1 : 5,000) or Thiersch's lotion should be employed. At the con- 
clusion of the operation, however, the wound should be well flushed with 
stronger (1 : 1,000) corrosive-sublimate solution. 

(b) Removal of all parts, soft or osseous, that are manifestly diseased, 
whether carious, cheesy, gelatinous, or granulating, is a most important 
condition of success. On the other hand, no apparently healthy parts ought 
to be needlessly sacrificed. 

Note. — Without antiseptics partial excisio?is of joints were much more dangerous than total 
ones. The reason of this was the fact that after total excision the conditions for effective drainage 
were much better than after partial exsections. Suppuration of resection wounds was the rule 
then, and is now the exception, hence partial excisions are just as safe at present as total ones. 

To prevent further dissemination of the tubercular virus from the site 
of the operation, ample incisions must be made. They will enable the sur- 
geon to reach every part of the diseased joint without the employment of 
undue force by retractors. 

Diseased bones are removed by the saw in adults ; in children, they can 
be pared off with a strong scalpel. Pockets filled with caseous matter are 
scooped out with the sharp spoon. The entire capsule must be removed by 
dissection luith curved scissors and a mouse-tooth forceps. 

(c) To control hemorrhage, artificial anaemia should be used during the 
operation wherever possible. Where, as in the shoulder- and hip-joints, 
Esmarch's band can not be well applied, each vessel must be secured and 
tied as soon as it is exposed or cut. 

Artificial ancemia may be kept up till the dressings are completed ; but 
care must be taken to search out and tie every cut vessel before closing the 
wound. How to do this is described in the paragraph on artificial anaemia 
in amputations (page 66). 

(d) Preservation of the usefulness of the limb, or of the function of the 
exsected joint, is the last, but not least, requirement to be fulfilled. 

The knee- and occasionally the hip-joint will, as a rule, be more useful 
if firmly anchylosed than otherwise. Mobility of the other joints, however 
limited, is more desirable than anchylosis. 

To favor anchylosis, the sawed surfaces of the bones to be united must 
be brought and kept in firm apposition by posture, suture or nails, and a 
contentive dressing. 

Where preservation of mobility is aimed at, 'the periosteal covering of 
the exsected bones must be preserved by subperiosteal dissection. The peri- 



TEEATMENT OF TUBERCULOSIS. 277 

osteum can be stripped off easily with an elevator or Sayre's " oyster-knife," 
except at the site of the insertion of muscles, where the aid of the scalpel 
or a sharp raspatory must be accepted. The re-formation of the normal 
contour and function of the prospective joint depends in a great measure 
upon the preservation of the periosteum. 

With drainage by rubber tubes, an exact suture of the external wound, 
and Schede's modification of the aseptic dry dressing, the operation is com- 
pleted. Where Esmarch's constricting band was left in situ until the com- 
pletion of the dressings, these must be made rather ample, and a good deal 
-of elastic pressure by snug bandaging must be brought to bear upon the 
wound to control oozing and soiling of the dressings. The dressed limb 
must be suspended or otherwise elevated in a vertical position until the 
hyperemia due to vascular paresis disappears. Care must be taken to ascer- 
tain, by the look of the tips of the toes or fingers, that circulation is not 
wholly cut off by strangulating compression of the bandage. 

Should the oozings penetrate the dressing in the course of a few hours, 
the soiled surface of the bandage must be thickly dusted with iodoform pow- 
der to favor exsiccation. A few compresses of sublimated gauze are placed 
over the bloody spots, and are secured by a few turns of a roller bandage. 

In case of continued oozing, further loss of blood can be checked by the 
temporary application of a Martin's elastic bandage over the dressings. If 
the soiling is too extensive to admit the use of such partial measures as 
those just indicated, the external compresses composing the dressing must 
be removed and replaced by clean ones. The deepest part of the dressing, 
however, should not be disturbed. 

b. After-Treatment. — Where, as for instance, in the elbow, mobility 
of the joint is aimed at, absolute fixation by splint should continue only so 
long as the drainage-tubes are withdrawn and the incisions are firmly 
healed. Passive, but especially early passive motions, so warmly recom- 
mended by older authors, are harmful, and not to be compared as regards 
their value with active exercises. 

The disadvantages of early passive motions can be summed up in this : 
Before the re-establishment of the normal condition of the tissues pertain- 
ing to an exsected joint — that is, before the disappearance of the swelling 
and rigidity of the soft parts — all motions, active and passive, will be pain- 
ful. Active motions will be limited to a harmless compass by the pain for- 
bidding extensive movements ; but passive motions, done without regard to 
the pain and struggles of the resisting patient, will be, and as a matter of 
fact often are, carried far beyond the limit of harmlessness. The forcible 
stretching and crushing together of the newly united parts and of the young 
connective tissue are inevitably followed by minute ruptures and lacerations. 
Eenewed exudation and a diffuse state of adhesive inflammation are set up, 
which will cause the persistence or even an increase of the painful swelling 
and induration primarily found about the exsected joint. The greater the 
surgeon's energy the worse the result, and in many cases anchylosis is 
brought on by the very measures intended to prevent it. 
37 



278 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



If the surgeon, on the other hand, patiently awaits the time of spontane- 
ous detumescence, which, with antiseptic measures and proper fixation, will 
occur at about the fourth or fifth week after the operation, gentle motions 
will cause no pain, and will encourage the patient to active exercise of the 
joint. The pain felt on excessive movement will serve as a wholesome 
check against undue zeal ; the improvement of nutrition due to active exer- 
cise will hasten the definitive involution of the inflammatory products. 
Thus, day by day will the strength and amplitude of the active movements 
be increased, and by dint of painless attrition new articular surfaces will be 
ground and polished into shape. The psychological and moral part of the 
after-treatment is of the greatest importance here. The conviction that 
active movements of the exsected joint are possible without pain will inspire 
the patient with courage. Unceasing active exertion will work wonders, 
based upon the patient's confident expectation of a good final result. 

The acute pain produced by frequent and merciless passive motion, and 
the subsequent tenderness engendered by it, will convert the after-treatment 
to a source of constant terror and moral depression to the patient. His 
courage will be shattered, and no amount of persuasion or coercion will in- 
duce him to inflict pain upon himself by active movements. And it will 
be a lucky circumstance if the physician's illy conceived attempts at estab- 
lishing a normal function are frustrated at an early date by the patient's 
resistance. Subsequently, rest and the disappearance of local pain will 
naturally elicit first timid, later bolder, attempts at active movement, and 
after all, an unexpectedly good function may thus result. 

The aid afforded to Nature should be very discreet indeed, here as well 
as in other branches of surgery. 

Aside from active movements, massage and faradism are powerful aids 

in re-establishing normal 
circulation and lost mus- 
cular power. 

Special Part, 
a. Shoulder - Joint. 
— The application of arti- 
ficial anaemia in exsection 
of the shoulder-joint is al- 
ways difficult and some- 
times entirely impracti- 
cable. After due cleans- 
ing and disinfection of 
the field of operation, the 
hand and forearm of the 
affected limb are envel- 
oped in a clean towel wrung out of mercuric lotion (Fig. 202), and, the 
rest of the body being well protected by rubber sheets and clean towels, an 
ample anterior incision is carried from midway between the acromion and 




Fig. 202, — Exsection of shoulder-joint. Bead of humerus 
turned out of glenoid cavity. 



TEEATMENT OF TUBERCULOSIS. 



279 




Fig. 203. — Exsection of shoulder-joint. Location of drainage on 
the posterior aspect of the shoulder. 



the coracoid process down to the limit of the upper third of the humerus. 
The tendon of the long head of the biceps is held aside by a blunt hook. 
The capsular ligament and periosteum are raised 
from the bone by means of an elevator, or, where 
the insertions of the muscles offer greater resistance, 
by a sharp raspatory. This step will be very much 
facilitated by gradual inward and later by outward 
rotation of the humerus, to be done by an assistant 
holding the hand and bent elbow. After decapita- 
tion of the humerus, 
the capsule is to be 
exsected by forceps 
and blunt scissors. 
This, the most diffi- 
cult part of the op- 
eration, will be very 
easy if the primary 
incision is ample. If 
found diseased, the 
glenoid fossa is thor- 
oughly scraped, and, 
a counter-incision being made at the posterior aspect of the joint, a drain- 
age-tube is inserted there. (Fig. 203.) The first incision is closed by several 
tiers of catgut sutures, and, the wound being dressed, the limb is bandaged 
to the thorax in a flexed position. Later on, an arm-sling will serve as an 
adequate support. (Figs. 204 and 205. ) 

The dressings are changed on the tenth day, when the drainage-tube 
can also be removed. In grown subjects the operation will generally result 
in a somewhat loose joint, lacking especially the power of active abduction. 

Case I.— Anna Haupt, aged sixty. Large subdeltoid cold abscess; no fistula. 
May 25, 1879. — Exsection of right shoulder-joint at the German Hospital. Head 
of humerus bare of cartilage and carious ; caries 
of glenoid cavity. August 3d. — Discharged cured. 

Case II. — Willie Kunz, aged four. 
January 25, 1882. — Exsection of left 
shoulder-joint for cheesy osteitis of the 
head of humerus at the German Dis- 
pensary. March 10th. — Discharged 
cured. 

Case III.— August Arnold, aged 
three and a half years. April 17, 
1883. — Exsection of left shoulder- 
joint for caseous foci in the head of 
the humerus at the German Hos- 
pital. May 30th. — Discharged cured. 

Case IV. — Harry Gross, aged two. September 30, I884. — Exsection of right 
shoulder-joint for caseous osteitis at Mount Sinai Hospital. Several relapses required 




Fig. 204. 



-First dressing after exsection of 
shoulder-joint. 



280 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 205. — Arm- sling. (Esmarch.) 



renewed scraping of the fungous granulations. January 15, 1885. — Patient died of 
meningeal and peritoneal tuberculosis with ascites. 

Case V. — Carl Buchowsky, type-setter, aged twenty-eight. Synovial tubercu- 
losis of right shoulder-joint of six years' 

standing; three fistulas. April 26, 1887. „/ 

— Exsection of the shoulder-joint at the 
German Hospital. In May patient was 
discharged not cured, with two fistulas, 
but with a very fair prospect of an ulti- 
mate cure, the cause of his discharge be- 
ing a disciplinary breach of the rules of 
the hospital. 

b. Elbow. — The patient's shoul- 
der, hand, and part of his forearm 
are wrapped in clean towels soaked 
in corrosive-sublimate lotion. (Fig. 
206.) The arm is vertically elevated 
for a few minutes, and elastic con- 
striction is applied to the humerus 
below the shoulder. Langenbeck's 

posterior longitudinal incision will give most space. (Fig. 207.) In denude 
ing the internal epicondyle, injury of the ulnar nerve should be guarded 
against by closely hugging the bone with the instrument. The diseased 
portions of the bones being removed, the entire capsular ligament is ex- 
sected, care being taken not to overlook any cheesy foci. 
One or more drainage-tubes are inserted, preferably 
through pre-existing sinuses, and the incision is closed 
by catgut sutures. The region of the elbow is envel- 
oped in an ample Schede's dressing, held down by rather 
tight bandaging. The extended arm is fastened to a pair 

of lateral paste- 
board splints, 
and is kept in 
the vertical po- 
sition till the 
flushed appear- 
ance of the pro- 
jecting tips of 
the fingers due 
to vascular pa- 
ralysis has dis- 
appeared. (Fig. 
208.) 

Note. — The simplest way of making suitable pasteboard splints is by tearing them out, of a 
sheet of pasteboard. (Fig. 209.) The advantage of tearing over cutting is in the circumstance 
that the edges of the torn splint are not abrupt and hard, but become soft and thin on account 
of the gradual thinning of the torn edge. Snug adaptation and a good fit result therefrom. Care 




Fig. 206. — Exsection of elbow-joint. Patient ready for operation. 



TREATMENT OF TUBERCULOSIS. 



281 



must be taken to 
ascertain first the 
trend of the fiber 
of the pasteboard, 
as the edge of the 
splint torn across 
the direction of 
the fiber will turn 
out uneven, and a 
splint thus made is 
apt to break. 

The dress- 
ings should be 
changed, and 
the drainage- 
tubes removed, 
a fortnight aft- 
er the exsection. 
The elbow is 
to be re-dressed 
and put up at 
the same angle. 




Fig. 207. — Posterior longitudinal incision ot elbow-joint. 



As soon as the drainage-holes are healed, passive, but especially active, exer- 
cises should commence, aided by massage and faradism applied to the muscles. 
After partial exsection of the joint, little lateral mobility will be observed. 
In these cases no special apparatus will be required. But where much lateral 
mobility, due to extensive removal of bones, is present, the use of an appa- 
ratus confining the movements of 
the joint to flexion and extension 
will be required. (Figs 212, 213. ) 




Fig. 208. — Finished dressing and eleva- 
tion after exsection of elbow-joint. 




Ftg. 209. — Tearing into shape of pasteboard splint. 



Note. — The apparatus can be made by the surgeon without the aid of the instrument-maker 
in the following manner : Two strips of very light hoop-iron or sheet zinc, about one inch wide 



282 



EULES OF ASEPTIC AND ANTISEPTIC SUEGEEY. 



and from four to six inches long, are loosely riveted to each other at their ends, so as to form a 
hinge. Two pairs of such hinges are necessary. The patient's arm being protected by a few- 
turns of a flannel bandage, a light silicate-of-soda wristlet and arm-band (Fig. 212) are applied. 
To these are fitted the hinges, one externally, the other internally, by giving their middle a suitable 
bend to allow for the expansion of the soft tissues on flexion of the joint (see front view). By 




Fig. 210. — Pattern for angular pasteboard splint. (Esmarch.) 

a few more turns of the silicate bandage, the hinges will become immured in the wristlet and 
arm-band. As soon as the splint is dry, it is split longitudinally on its anterior aspect, to per- 
mit its removal and further fitting. Shoe eyelets are put in along the edges of the longitudinal 
cuts for lacing. Two pairs of small-sized brass screw-eyes are let in on each side of the wristlet 
and arm-band, to serve for the attachment of solid rubber bands, which are to aid the efforts of 
the flexor muscles in bending the elbow. To prevent slipping down of the apparatus, a cap is 
made of a piece of sole-leather, softened in hot water, which is 
molded to the shoulder. It is left on till dry. A button is let 
into it to serve for suspending from it the apparatus by a short 
strap. Another strap slipped over this button is passed around the 
thorax of the patient, and is buckled in the opposite axilla. (Fig. 213.) 
Flexion and extension are to be done by the patient at regular 
intervals from six to eight times a day, by raising first an empty pail 
from the ground twenty or thirty times. The elbow flexed by the 
rubber bands is extended by the weight of the pail. As the strength 



Mi 





Fig. 211. — Angular pasteboard splint in situ. (Esmarch.) 



of the flexors improves, active flexion is to be tried, and the weight of the pail is to be gradu- 
ally increased by putting more and more sand or gravel into it. The apparatus is to be daily 
removed, for cleansing and the application of massage and faradism to the arm. 

The use of the apparatus can be abandoned with the disappearance of 
lateral mobility. The first of the nine cases of exsection of the elbow-joint 
performed by the author was done without aseptic precautions. Study of 
the history of this case and comparison with the other cases is earnestly 
recommended to the reader. 



TREATMENT OP TUBERCULOSIS. 



283 



Case I. — Joseph Keck, silk- weaver, aged thirty- nine. Synovial tuberculosis of 
right elbow, with cold abscess situated beneath the supinators; no fistula. December 
10, 1877. — Total exsection of the joint at the rooms of the patient 
without any aseptic precautions. Trochlea, ulna, and radius ca- 
rious. Drainage, suture, and suspension in an interrupted wire ">s. 
splint. Wound was dressed with a compress, to be kept moist by \ 
immersion in tepid water. The thermometer indicated 103° Fahr. 
on the evening of the same day, and never descended below this . 

figure until December 24th. Frequently the temperature rose to )^__ — } _£ 

105° Fahr. December 13th. — Wound fetid, inflamed, suppurating; 
stitches were removed, whereupon the wound gaped open, and was 
seen to be covered with a thick, adherent coating. December 15th. 
— Great swelling and dusky appearance of cubital region. Incision 
of abscess near triceps tendon. December 17th. — Rigor, elbow still 
more swollen, December 18th. — Rigor. December 19th. — Rigor 
and great debility. December 22d. — Rigor. December 2Jj.th. — 
Evacuation of another abscess from the upper angle of the wound, 
whereupon the temperature fell to 99° Fahr., and the dusky swell- 
ing of the limb moderated. Apparently the fever was due to osteo- 
myelitis of the lower end of the humerus. December 25th. — Ery- 
sipelas set in, commencing from an abrasion caused by the splint. 
Temperature, 105° Fahr. December 29th. — Erysipelas extended to 
shoulder-joint, where it disappeared. March 10th. — Incised three 
abscesses of the forearm, wound granulating and contracting; re- 
moval of sequestrum of humerus. June l^th. — Removal of six 
small sequestra from humerus. Active and passive movements com- 
menced. July 12th. — Flexion to 90°; extension normal. Sinuses 

were scraped in anaesthesia. 
Lateral mobility diminishing. 
September 29th. — Application 
of articulating apparatus. Oc- 
tober 30th. — Patient was dis- 
charged cured with normal 
flexion and extension, with 
limited pronation and supina- 
tion, and slight lateral mobil- 
ity. May, 1887. — Arm sound 
and quite useful, in spite of slight lateral mo- 
bility. 

Case II. — Hermann Prieg, laborer, aged thir- 
ty-eight. November 15, 1880. — Total exsection 
of elbow-joint at the German Hospital for syn- 
ovial fungous disease with fistula, under anti- 
septic precautions. Feverless course, primary 
union. February 27th. — The patient was dis- 
charged cured, with limited motion and no lat- 
eral mobility. 

Case II I. — Lena Bois, aged twelve. March 
llf,, 1882. — Partial exsection of elbow-joint for caseous ostitis of the olecranon, from 
which a sequestrum was removed at the German Hospital. April 30th. — Discharged 
cured with limited motion. 




Fig. 212.— Appara- 
tus for after-treat- 
ment of exsection 
of elbow-ioint. 



Fig. 213. — Elbow -joint apparatus in 
position. 



284 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Case IV. — Theodore Noirot, metal-worker, aged twenty-eight March 9, 1882. — 
Total exsection of elbow-joint at the German Hospital for osseal tuberculosis of 
humerus, ulna, and radius. Primary union of the deep parts of the wound. May 9th. 
— Discharged cured with almost perfect function of the new joint. 

Case V. — Leonhard Fath, aged seven. Cheesy tuberculosis of olecranon. October 
21st. — Partial excision at Mount Sinai Hospital. November 10th. — Discharged cured 
with limited motion, which improved somewhat in the course of the following six 
months. 

Case VI. — Luigi Martini. May 27, 1886. — Total exsection for osseal tuberculosis 
of humerus, ulna, and radius at the German Hospital. Primary union. June 6th. — 
Discharged cured with limited motion. Owing to neglect of the parents, who failed 
to present the boy for after-treatment, the joint became almost entirely stiff. 

Case VII. — Charles Dunninger, aged two and a half. April 22, 1886. — Total ex- 
section for extensive osseal tuberculosis at the German Hospital. Primary union and 
ultimately excellent function. Discharged cured August 1st. The discharge was 
delayed by the inability of the parents to take care of the child. 

Case VIII. — Nathan Blumenbach, aged seven. Extensive osseal tuberculosis with 
several abscesses. February 9, 1886. — Incision and drainage of the abscesses, followed 
by severe chill and fever, very likely due to septic infection at the time of the incision. 
February 11th. — Total exsection at the German Hospital, followed by prompt low- 
ering of the temperature from 105° Fahr. to 99° Fahr. Primary union. March 14-th. — 
Discharged cured, with good function. 

Case IX. — Kudolph Boenke, aged twelve. Cheesy osteitis of olecranon with 
abscess. March 30th. — Partial excision. A shell of the olecranon adhering to the 
triceps tendon was preserved. Suture ; no drainage-tubes. April 12th. — Change of 
dressings; primary union. Elbow put up at a right angle. April ll^th. — Passive 
motion ; fixation at an acute angle. Every few days passive motions were done, and 
the arm was put up at a different angle. This led to considerable irritation and dense 
oedema of the elbow, compelling cessation of the passive movements. The mistake 
made in the after-treatment was further emphasized by the detachment and expulsion 
of the necrosed remnant of the olecranon. Two fistulse discharging bloody serum 
remained open. May 30th. — The fistulae were scooped out with the sharp spoon. No 
improvement following, June 10th, the wound was reopened in ether anaesthesia. 
Gelatinous infiltration of the soft parts surrounding the joint, tuberculosis of the radio- 
ulnar junction and caries of the resected bone-surfaces were found. Total exsection 
being performed, the arm was dressed and put up in a splint as usual, and remained 
undisturbed for five weeks, after which active exercises were commenced. No passive 
movements were done at all. By August 1st, active flexion and extension were normal, 
and the arm had regained its power almost completely. 

c. Wrist and PIand. — Langenbeck's dorsal incision affords the most 
favorable approach to the radio-carpal as well as especially to the intercarpal 
and metacarpo-carpal joints. (Fig. 214.) With artificial anaemia a very 
thorough removal of the diseased bones and capsular ligaments can be done. 
The wound is drained and closed by catgut sutures, and, being inclosed in 
an aseptic Schede's dressing, the hand is fastened to a short volar splint 
of wood, which should not extend beyond the metacarpo-plialangeal joints. 
The patient is directed from the second day on to practice active motions of 
the fingers. This will achieve two good purposes. First, extreme atrophy 
of the muscles will be prevented ; and secondly, adhesions of the tendons 



TREATMENT OF TUBERCULOSIS. 



285 




Fig. 214.— Langen beck's dorsal incision for exsection of wrist. 



Primary union. September 30th. — 



and tendineal anchylosis will be avoided. The active movements, feeble and 
hardly perceptible at first, will become visibly stronger as the healing pro- 
gresses, and thus a 
very acceptable degree 
of usefulness of the 
hand may be regained. 

Case I. — Herman Ro- 
sengarden, clerk, aged 
thirty-four. June 7, 1882. 
— Total exsection of wrist 
at Mount Sinai Hospi- 
tal for synovial tubercu- 
losis with several fistulas. 
Primary union. August 
7th. — Discharged cured. 
When leaving, he played 
on an accordion. 

Case II. — A woman, 
aged thirty-eight. Au- 
gust 25, 1885.— Total ex- 
section of left wrist at the German Hospital 
Discharged cured, with moderate function. 

Case III. — Matthew Dempsey, laborer, aged twenty. June 22, 1885. — Total exsec- 
tion of wrist for osseal tuberculosis of carpal bones at Mount Sinai Hospital. Primary 
union and very fair function were secured. The discharge of the patient was delayed 
till the end of the year by several pulmonary haemorrhages. 

Case IV. — Paul Klein, laborer, aged forty-one. February 25, 1886. — Total exsec- 
tion of wrist for osseal tuberculosis with several fistulas at the German Hospital. The 
patient was suffering from far-gone pulmonary phthisis. Primary union, but speedy 
relapse of tuberculosis in the interior of the wound and the cicatrix. April 11th. — 
Discharged not cured. 

Case V. — Max Friedmann, aged ten. April 4th. — Partial excision of wrist-joint 
on account of caseous osteitis of styloid process of ulna, with involvement of the radio- 
ulnar and radio-carpal joints. Primary union. April 20th. — Discharged cured, with 
good function. 

Case VI. —Ferdinand Ohle, aged five and a half. March 22d. — Total exsection ot 
left wrist at the German Hospital for osseal tuberculosis. Wound healed by primary 
union. Patient remained in hospital for treatment of simultaneous tubercular disease 

of the knee-joint. 

d. Hip-joixt. — The author's 
very limited experience in the op- 
erative treatment of hip-joint dis- 
ease, extending over 
three cases only, does 
not afford sufficient 
material to base any 
trustworthy conclu- 
sion upon. Moreover, 

Fig. 215.— Exsection of hip-joint. Position of patient. two of the three Cases 

38 




286 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 





Fig. 217. — Completed dressing after hip-joint 
exsection. 



Fig. 216.— Exsection 
of hip-joint. Ar- 
rangement of pro- 
tective cloths. 



were, at the time of the operation, 
healed by anchylosis, as far as the affec- 
tion of the joint proper was concerned. 
They came under the author's care on account of tubercular processes 
located on the pelvic bones, requiring operative treatment. 

Case I. — Albert Gaupp, aged thirteen. Anchylosed hip-joint ; caseous ostitis of 
os ilium with complicated sinuses and pelvic abscess. 
August 12, 1882. — Incision and drainage of various sinus- 
es and of the pelvic abscess; removal of a considerable 
portion of the ilium and os pubis with mallet and chisel 
at the German Hospital. Jan. 21, 
1883. — Discharged much improved. 

Case II. — Samuel Amster, aged 
ten. Tubercular coxitis, with sinus, 
of two years' duration. Decem- 
ber 3, 1885. — Exsection of hip-joint 
above the trochanters at Mouut Si- 
nai Hospital. Removal of the ace- 
tabulum, which was found perfo- 
rated. After-treatment with weight 
extension. January 18 and 26, 
1886. — Revisions of wound, on ac- 
count of the presence of exuberant 
granulations in the drainage-tracks. 
May 10th. — Discharged cured. In 
November the patient was readmit- 
ted on account of pelvic disease. A 
fistula had been established below 
the anterior-superior spine, leading 
to the inner aspect of the ilium. 
December 15th. — Three sequestra 
were removed by an incision made 
along the crest of the ilium. In 
June, 1887, the patient was dis- 
charged cured. 

Case III. — John Renk, aged 
thirty-nine. Anchylosis of right 





Fig. 218. — Exsection of hip 
joint. Final result. Ante 
rior view. (Dr. F. Lange', 
case.) 



Fig. 219. —Hip-joint 
exsection. Lateral 
view. (Case of Dr. 
F. Lange.) 



TREATMENT OF TUBERCULOSIS. 287 

hip-joint with shortening of limb, the result of hip disease contracted in childhood, 
which was treated orthopedically. No fistula. Tuberculous ostitis of ilium and adjoin- 
ing part of os pubis. March 17, 1887. — At the German Hospital, exsection of great 
trochanter and remnant of neck of thigh as a means to gain access to the diseased 
focus. An abscess was opened in front of the joint, and, being followed up, led to a 
number of sequestra located at the juncture of ilium and os pubis, which were removed. 
The softened and broken-down walls of the cavity containing the sequestra were scraped 
and gouged. Drainage and suture of the wound. Uneventful course of healing. In 
August the patient was still under treatment. A sinus persisted at the site of the 
operation. The discharge was very scanty and serous, however, promising early clos- 
ure. Anchylosis firm again. Patient walking without support. Cured October 1. 

e. Khee-joent. — White swelling of the knee-joint in adults of the 
laboring class can, for various external reasons, rarely be treated by ortho- 
pedic measures. In children, a rational mechanical and general treatment 
will often reward the patience and skill of the physician by excellent results. 
Exsection of the infantile knee-joint is to be avoided as long as possible, on 
account of the great shortening that is caused by the removal of the epi- 
physes adjoining the knee, on which depends the growth of the thigh and 
tibia. In adults exsection is the shortest and safest way of eliminating the 
tedious morbid process, and substituting firm anchylosis for a useless joint. 
Arthrectomy, or exsection of the capsular ligament alone, as suggested by 
Volkmann, has not been attended with good success in the experience of 
the author. Two cases — one in an adult, the other in a child — resulted in 
relapse of the tubercular affection, although great care was taken in remov- 
ing the entire capsule. A third case was permanently cured. 

Case I. — S. Lindholm, metal-worker, aged twenty-seven. February 28, 1882. — 
Arthrectomy and removal of the patella were done for fungous arthritis of the knee- 
joint. Primary union of wound followed. March 22d. — A relapse occurred in the 
cicatrix, which gradually involved the articular aspects of the femur 
and tibia. Amputation of the thigh was performed by Dr. I. Adler. 

Case II. — Fred. Ohle, aged five and a half. Tubercular arthritis 
of the knee-joint. January 26, 1887. — Arthrectomy was performed 
at the German Hospital. March 22d. — Revision and scraping of the 
entire cavity on account of tubercular relapse. In May the boy was 
still under treatment. 

Case III. — George Kuhn, butcher, aged twenty-six. July 6, 1882. 
— Arthrectomy and removal of carious patella was performed at the 
German Hospital. November 5th.— Discharged cured with slight mo- 
bility of joint. 

In children, exsection should be strictly limited to the re- 
moval of actually diseased parts of the bones. By Schede's 
plan of dressing the wound, the hollow space remaining be- Halm's supra 
tween the incongruent joint-surfaces will be filled up by an fon^orexsec 




organizing blood-clot, and firm union may be attained. tion of knee- 

Case IV. — Eva Greenburg, aged eight. Osseal tuberculosis of the 
knee-joint with sequestrum in the external condyle; granular ostitis of the internal 
condyle; multiple cheesy deposits in the thickened capsule; subluxation backAvard of 



288 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



the tibia with rectangular contraction. August 12, 1886. — Partial exsection of knee- 
joint at Mount Sinai Hospital. After the removal of the sequestrum, a deep recess 

was left behind in the intercondy- 
lar notch. Patella and entire cap- 
sule were removed; the ham-string 
tendons were divided to prevent 
recontraction. The tibia was su- 
perficially pared, and the bones 
were held in apposition by a nail 
driven diagonally through femur and 
tibia. Plaster-of-Paris splint over 
a Schede's dressing. Several re- 
lapses in the popliteal space re- 
quired repeated scrapings. The pa- 
tient had one attack of erysipelas. 
By reason of these complications, 
cure was delayed. February 27, 
1887. — Patient was discharged cured 
with firm anchylosis. 

Total exsection of the knee-joint is usually 
done by the author in the following manner : 
After careful shaving, scrubbing, and disinfec- 
tion of the region of the knee, the foot and leg 
and the thigh of the diseased 
limb are wrapped in clean 




Fig. 221.— Exsection of knee- 
joint. Exposure of articular 
planes. 




towels wrung out of corrosive- 
sublimate lotion. The limb is held elevated in the ver- 
tical position for five minutes to deplete its vessels, and 
the constricting elastic band is applied well up near the 
root of the thigh. The knee is flexed, and an incision, 
commencing at the middle of one condyle of the femur, 
and extending in a semicircular line above 
the patella to the middle of the other con- 
dyle, is carried into the joint. (Fig. 220.) 

Note. — The transverse incision 
above the patella, proposed by Eugene 
Hahn, of Berlin, has many advantages 
over the incision made below the knee- 
pan. The chief one is the free access 
it affords to the bursa of the quadri- 
ceps, which must be carefully exsected 
along with the capsule. 

The crucial ligaments are 
cut close to their attachment 
to the femur, and the patella, 

semilunar cartilages, and entire capsule, together with the bursa of the 
quadriceps, are exsected with mouse-tooth forceps and curved scissors. 
Care must be taken not to overlook some small bursse situated behind 



Fig. 222. 
Exsection of 
knee - joint^ 
A view of 
the sawed 
surfaces. 



TREATMENT OF TUBERCULOSIS. 



289 




the head of the tibia, which regularly communicate with the interior of 
the joint 

The condyles of the femur are sawed off, the plane of section correspond- 
ing to the transverse diameter of the epiphysis of the femur. (Fig. 222.) 

Note. — Disregard of this 
rule will lead to anchylosis 
in the bow-leg position. 

mi >■ i Eig. 223.— Steel nail. 

ine articular as- 
pect of the tibia is sawed off at a right angle to the long axis of this bone. 

All visible orifices of vessels are secured by ligature. They can be made 

visible by compress- 
ing the vicinity of 
the wound with both 
hands. 

If the transverse 
incision was not made 
long enough to permit 
of an easy arrangement 
of the drainage-tubes 
in the angles of the 

wound, it should be sufficiently lengthened. The inner ends of the tubes 

should reach into the popliteal space just behind the sawed surfaces, and the 

tubes must not be compressed and occluded by the tension of the soft parts 

surrounding them. 

The limb is placed upon a long cushion 

covered with a clean towel wrung out of 

corrosive-sublimate lotion, and, while the 

sawed surfaces are held in exact apposition, 

two or four long steel nails, previously well 

disinfected by heating in an alcohol flame, 

are driven diagonally 

through femur and 




Fig. 224. — Exsection of knee-joint, 
view. 



Sutured wound. Anterior 




tibia, so as to firmly 
lock the bones in 
the desired position. 
(See Fig. 79, page 
84.) The cutaneous 
incision is united by 
a sufficient number 
of catgut stitches. 
The limb is raised 
by the foot from the 
cushion, which is 

then removed. Strips of disinfected rubber tissue are slipped under the 
safety-pins, securing the ends of the trimmed drainage-tubes, and an oblong- 
compress of iodoformed gauze is laid over the entire line of union. A suit- 



Fig. 221 



-Exsection of knee-joint. Sutured wound. Lateral view. 
Heads of steel nails projecting from skin. 



290 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 226. — Immediate dressing of wound after 
exsection of knee-joint. 



able number of sublimated gauze compresses are arranged around the knee- 
joint, and two short lateral splints of veneer or thin board are firmly band- 
aged on to serve as a deep support. (Figs. 226 and 227.) Over these 

comes an ample external dressing of corrosive- 
sublimate gauze, also firmly held down by a gauze 
bandage. The towels are removed, and the un- 
covered parts of the limb are enveloped in a layer 
of borated cotton to equalize the outline of the 
extremity. Two long, lateral, pasteboard splints, 
held down by a muslin or crino- 
line bandage, complete the dress- 
ing for children or adolescents. 
(Fig. 228. ) The more voluminous 
limbs of adults are better secured 
by a solid circular plaster-of- Paris 
splint. 

The limb is vertically elevated, 

and the constricting rubber band 

is removed. Return of circulation 

is attested by the pink color of 

the toes. As soon as these turn pale, the extremity can be brought into 

the horizontal position. 

If asepticism was well maintained, little aseptic fever and no severe 
pain will follow the operation. The dressings should remain undisturbed 
for thirty days, to afford a good chance for bony union. After thirty days 
the splints and dressings can be removed, and the nails and drainage-tubes 
can be withdrawn. The remaining sinuses are to be dressed lightly, the 

limb is incased in a silicate-of-soda splint, and 
the patient is ordered to walk about on crutches, 
whether osseous union be present or not. Gradu- 
ally the use of crutches is dispensed with, and 
the patients generally learn to walk very well on 
an elevated sole, compensating 
the shortening. 

Of twelve cases of total ex- 
section done by the author for 
tuberculosis, eleven recovered. 
One died of meningeal tubercu- 
losis. 

Case I.— Fred. Fuchs. aged sev- 
en. Osseal relapsing tuberculosis 
after arthrectomy, done by Dr. F. 
Lange in June, 1885. March 4, 
I884. — Total exsection, done at the 
German Hospital, reveals two periarticular abscesses and five cheesy foci in tibia and 
femur. Suppuration of wound. March 10th. — Incision of abscess on outer aspect of 




Fig. 227. — Deep support of exsected knee-joint by 
short lateral board splints. 



TREATMENT OF TUBERCULOSIS. 



291 




Fig. 228. — External long lateral pasteboard splints after exsec- 
tion of knee-joint, applied over complete dressing. 



knee. April 23d.— Separation of epiphysis of tibia. Separated epiphysis firmly 
united to femur. In April symptoms of meningeal tuberculosis developed, to which 

patient succumbed May 31st. 

In one of the remaining eleven cases ampu- 
tation of the thigh became necessary on account 
of suppuration. 

Case II. — H. Desmond, professional athlete, aged 
thirty. Extensive destruction of right knee-joint by 
tuberculosis, complicated with pyogenic 
infection. The knee, leg, and thigh con- 
tain a large number of abscesses. Pro- 
fuse secretion from seven 
fistula?. The case was not 
suitable for exsection, and 
amputation was advised. 
But, at the patient's ur- 
gent request to make an 
attempt to save his limb, 
February 14, 1884, total 
exsection was done at the 
German Hospital. As sup- 
puration was expected, the 
extremity was fixed to an interrupted dorsal suspension splint made of hoop-iron and 
plaster bandages. Profuse suppuration followed with evident prostration, and, April 
19th, amputation of the thigh was performed. The wound healed by granulation, and 
in June patient was discharged cured. 

Ten cases were cured with preservation of the limb. In nine of these, 
firm bony anchylosis was secured. One case terminated in the formation 
of ligamentous union. 

Case I. — Niclas Gies, carpenter, aged fifty -four. Synovial tuberculosis with high 
temperatures and emaciation following a slight traumatism. Contraction of knee at 
an acute angle, with constant violent pain. February 19, 1886. — At the German Hos- 
pital, puncture yielded a small quantity of turbid bloody serum. In anassthesia the 
limb was straightened, and the joint was incised, irrigated, and drained. The fever at 
once disappeared, but flocculent pus commenced to exude from the tubes, confirming 
the assumption of tuberculosis. In view of the patient's age, his wretched general 
condition, due partly to disease and to chronic alcoholism, amputation was thought to 
be advisable. The plan of operation was changed at the operating-table, and total 
exsection of the knee-joint was done. HaBmorrhagic synovitis and a large cheesy 
deposit in the bursa of the quadriceps were found. Five nails were employed, with 
an aseptic dressing and pasteboard splints. Temporary compression by Martin's elas- 
tic bandage was applied to control secondary oozing. Esmarch's constrictor was 
removed after the completion of the bandage. A feverless course of healing fol- 
lowed. Change of dressings was done on the twenty-second day. Four nails were 
found loose, and were withdrawn. May 8th. — Scraping of drain age- tracks and 
removal of fifth nail. Ligamentous union was found and a plaster splint applied. 
June 12th-. — The sinuses were healed, and the patient was walking without the aid 
of stick or crutches in a light silicate-of-soda splint, though union of the bones was 
not perfect. 



292 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The other nine cases were in brief as follows : 

Case II. — Willie Bohn, aged three and a half. Osseal tuberculosis with fistulse. 
February 2, 1879. — Total exsection. April 2d. — Patient discharged cured. 

Case III. — Charles Harris, aged twelve. Osseal tuberculosis with fistulse; con- 
tracture and subluxation backward. June 13, 1881}. — Total exsection at the German 
Hospital. Hahn's incision; two nails; plaster- of-Paris splint. Some fever and deep- 
seated oedema of the region ot the knee followed. Sawed surfaces and flesh-wound 
united by primary union. The nails being withdrawn on the twelfth day, some pus 
exuded from their tracks, showing that the nails had apparently not been well disin- 
fected. Several revisions were required on account of unhealthy granulations in the 
drainage-holes„ February 4, 1881/.. — Patient discharged, with firm anchylosis and no 
fistula. 

Case IV. — Sussel Baerenknopf, aged nine. Osseal tuberculosis ; several fistulee ; 
subluxation. August 26, 1885. — Total exsection at Mount Sinai Hospital. Nails; plaster 
splint. September 25th. — Change of dressing. Drainage-tubes and nails were with- 
drawn ; firm anchylosis. October 10th. — Patient discharged cured. 

Case V. — Leonard Peters, waiter, aged nineteen. Synovial tuberculosis; no fis- 
tula. August 27, 1885. — Total exsection at the German Hospital. September 27th. — 
Plaster splint, dressings, drainage-tubes, and nails removed. October 9th. — Sinuses 
healed. October 19th. — Discharged cured with firm anchylosis. 

Case VI. — Bertha Deutsch, aged twelve. Synovial tuberculosis of five weeks' 
standing. Continuous high fever with rapid emaciation. Probatory puncture yielded 
scanty bloody serum. January 21, 1886. — Total exsection at Mount Sinai Hospital. 
The capsule was found studded with innumerable miliary tubercles. The fever disap- 
peared immediately after the operation. February 20th. — Plaster splint removed ; 
wound healed by first intention. March 10th. — Patient discharged cured, with firm 
anchylosis. 

Case VII. — Lizzie Boettger, aged twenty. Osseal tuberculosis of eighteen years' 
standing; rectangular contraction with subluxation backward. No fistula. February 
12, 1886. — Total exsection at German Hospital. March 10th. — Change of dressings ; 
primary union ; three nails and drainage-tubes were removed. April Ifth. — Patient 
complained of a good deal of pain in walking. A hard body could be felt under the 
skin on the outer aspect of the tibia. An incision exposed the head of the fourth nail, 
which had not been found at the first change of dressings. It was withdrawn with 
some force, a little blood exuding from its track. May 9th. — Patient was discharged 
cured. 

Case VIII. — Anna Sauer, aged twenty-two. Synovial tuberculosis with osseal 
ulceration of articular surfaces of both femur and tibia. No fistula. May 10, 1886. — 
Total exsection at the German Hospital. June 12th. — First change of dressings; 
primary union of soft parts ; delayed union of the bones. August 1st. — Discharged 
cured, with firm anchylosis. 

Case IX. — Katie Walter, aged eighteeD. Synovial tuberculosis with caseous de- 
posits in several recesses of the capsule, notably around and behind the crucial liga- 
ments. Caries of articular surfaces. No fistula. May 18, 1886. — Total exsection at 
the German Hospital. Slight fever following the operation, the dressings were re- 
moved May 26th. Marginal slough of the upper edge of the skin-wound. June 17th. 
— Nails were removed ; firm anchylosis. July 26th. — Patient discharged cured. 

Case X. — Emma Friedmann, aged twenty-seven. Synovial tuberculosis with caries 
of articular surfaces. No fistula. April 18, 1887. — Total exsection. April 22d. — 
Considerable secondary oozing necessitated a change of external dressings and plaster 
splint. Feverless course. May 23d. — Change of dressings ; primary union ; firm 



TREATMENT OF TUBERCULOSIS. 



293 



anchylosis. Tubes and three nails were removed ; a fourth nail could not be found, 
but was removed by incision on June 2d. Patient was discharged cured, with firm 
anchylosis, July 1st. 

Note. — To prevent the disagreeable necessity of 
cutting down for searching out a nail buried in the 
tissues, Dr. F. Lange's suggestion of fastening a silk 
ligature to the head of each nail before driving it in, 
seems to be very appropriate. 




Fig. 



229. — Arrangement of patient for 
Mikulicz's operation. 




I 



r^; : 



/. Ankle and Foot. — Tuberculous 
affections of the ankle-joint, or of the 
joints formed by the tarsal and metatar- 
sal bones, require, in case of the presence 
of one or more sinuses, exsection of the 
diseased parts. The long-continued dis- 
charges and lack of active exercise are 
very apt to reduce the 

general condition of the patient to serious anaemia and 
marasm, and, the disease extending to most of the com- 
plicated structures of the foot, may finally require am- 
putation. 

Early operations, especially i n chil- | 
dren, yield good functional results, as 
the extent of the removal can be lim- 
ited to the parts actually involved. 

Exsections 
^_ of the ankle or 

of other joints 
of the foot are 
not followed 
by good results 
in grown sub- 
jects, on ac- 
count of the technical difficulty of a complete removal 
of the synovial membrane. Relapse of the tubercu- 
lar process often supervenes, making amputation a 
necessity. 

In tuberculosis of the calcaneum or the astragalo- 
calcaneal joint, Mikulicz's osteoplastic exsection of the 
tarsus deserves employment. The lower ends of the 
tibia and fibula are sawed off as in Syme's amputation, 
and the articular surfaces of the cuboid and scaphoid 
bones are also sawed off, so as to fit the section of the 
tibia and fibula. (Fig. 230.) Nutrition of the ante- 
rior part of the foot is maintained by the dorsalis pedis artery, and the 
patient soon learns to walk on the balls of the toes, as in pes equinus. 
(Fig. 231.) 
89 




Fig. 230.— Diagram illustrating the plan of 
Mikulicz's" operation. (Esmarch. ) 




Fig. 231.— Shape of foot 
after Mikulicz's oper- 
ation. (Esmarch.) 



294 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

Case. — Hermann Mehle, barber, aged thirty-four. Synovial tuberculosis of the 
astragalo- calcaneal joint, with several fistulse situated to the right and left of the 
tendo Achillis. August 20, 1885. — Osteoplastic exsection of tarsus at the German 
Hospital. Primary union of the deep parts of the wound and of the bones. Mar- 
ginal sloughing of limited extent of the upper edge of the wound delayed the cure 
somewhat. October 10th. — Patient was discharged cured. 

Note. — This operation was employed by the author successfully in two more cases. In one, 
an epithelioma of the calcaneal region ; in the other, extensive chronic ulceration, due to frost- 
bite of the heel, was the indication to its performance. 

The preparation of the foot to be operated on is of very great importance, 
and thorough removal of effete epidermis and dirt is a necessary condi- 
tion of asepticism (see page 61). In exsection of the ankle, the bilateral 
incision gives very good access to the ankle-joint, though excision of the 
capsule will be found, at best, difficult to accomplish. 

It being desirable to produce a movable joint, subperiosteal dissection 
is to be aimed at, as in exsection of the elbow. As soon as the sinuses are 
healed, active use of the foot on crutches, aided by a shoe and brace, or a 
silicate-of-soda splint, should be encouraged. The tendency to posterior or 
lateral deviation of the foot will be best met by the long-continued use of a 
supporting apparatus of on,e kind or another. 

Case I. — Oaecilia Raab, aged twenty-two. Synovial tuberculosis of ankle-joint 
with several sinuses. November 9, 1882. — Exsection of ankle-joint at the German 
Hospital. Healing of the wound progressed favorably, when, November 30th, the 
patient contracted acute lobar pneumonia, in consequence of which she died Decem- 
ber 2, 1882. 

Case II. — George Eitt, aged six. Tuberculosis of ankle-joint caused by a cheesy 
focus in the astragalus. January 11, 1883. — Partial exsection of ankle-joint, part of 
the astragalus and the malleoli being removed. March 13th. — Scraping of the sinuses 
on account of relapsing tuberculosis. Sinuses persisted until the summer of 1884, when 
Dr. F. Lange, then on duty at the German Hospital, performed total exsection, which 
resulted in a cure of the tuberculosis, but with pseud arthrosis. July 20, 1885. — The 
author exsected the ligamentous mass interposed between the lower aspect of the tibia 
and fibula and the calcaneum, and fixed the latter to the tibia by a steel nail driven 
through from the planta pedis. Primary adhesion followed, with the formation of a 
slightly movable union of the tibia and calcaneum. September 5th. — The boy was dis- 
charged cured. In January, 1886, the brace worn until then was dispensed with. 

Case III. — Henry Holzfaller, aged four. Osseal tuberculosis of ankle-joint. March 
20, 1883. — Total exsection at the German Hospital. May 25th. — Patient discharged 
cured, with serviceable joint. 

Case IV.— Frida Schmoltz, aged three and a half. Osseal tuberculosis of ankle- 
joint with fistula. September 19, 1883.— Removal of external malleolus and part of 
astragalus, which contained a caseous deposit. October 15th. — Wound completely 
healed. Plaster-of-Paris splint applied. October 31st. — Silicate-of-soda splint applied, 
and patient directed to use the foot. August 4, 1885. — Normal position of foot; func- 
tion perfectly re-established. 

Case V. — I. S., aged eight. Osseal tuberculosis of ankle-joint with three sinuses. 
/September 26, 1883. — Partial exsection of ankle-joint; astragalus and inner malleolus 
were removed. November 15th. — Patient discharged cured, with improving function 
and normal position of the foot. 



TREATMENT OF TUBERCULOSIS. 295 

Case VI. — Jacob Deibel, farmer, aged twenty-three. Synovial tuberculosis of 
ankle and of astragalo-calcaneal joints. March 12, 1886. — Kemoval of both malleoli 
and of entire astragalus at the German Hospital. April 20th. — Patient discharged 
cured, with fair function of the foot, walking with the aid of a stick. 

Case VII. — Abraham Moses Goldenberg, aged four. Osseal tuberculosis of ankle- 
joint with sinuses. November 8, 1886. — Total exsection. Several relapses required 
repeated scraping with the sharp spoon. June -5, 1887. — The patient was discharged 
cured. 



PART IV. 



GONORRHOEA : 

ITS ANTISEPTIC TKEATMEJSTT. 



CHAPTER IX. 

NATURAL HISTORY AND TREATMENT OF GONORRHOEA. 

I. ETIOLOGY OF GONORRHOEA. GONOCOCCUS. 

Ik examining the purulent secretion produced by a virulent case of ure- 
thral gonorrhoea, the observer will detect with the microscope a number of 
dark, round objects resembling grains of fine gunpowder, that are vividly 
oscillating, and can be clearly distinguished from the adja- 
cent pus-corpuscles. The use of a stronger lens will reveal *£€?<* 
the fact that each individual coccus is divided in two un- SKf * 
equal halves. If staining is employed, the bodv of the coc- _ FlG - , 232 - . 

^ , . . J . Pure culture of 

cus will appear colored, and the dividmg-line will become eonococcus (700 
very conspicuous in the shape of a light, colorless streak. (From Bumm ) 
(Fig. 233.) 

Frequently an indication of incipient secondary division of each half of 
the coccus can be seen. Thus four cocci will be united to a seemingly single 
body, which can be aptly compared with four coherent biscuits, divided into 
equal quarters by two cross -shaped 

g®s« © « rooves - m 

™ " "~ The favorite location of the gono- * : $^^% 

Fig. 233. cocci found in the urethral secretions gik h ^S 

Development and - . . . :-/ 'iH "•----' 

fission of gono- is within the pus-corpuscles. This ^S& 

Bumm.) r ° m peculiarity belongs exclusively to the . r ^ ^ '3 

coccus of gonorrhoea detected by Neis- x ^ • fe 

ser in 1879, and represents its most important charac- "^T^^. 

teristic. (Fig. 234.) ^Sll^ttudd^^wSl 

Gonococci are to he found in the secretion of every gonococci; pus cell, 

J % . . . . lts protoplasm filled 

case of gonorrhoea, provided that no germicidal injec- with gonococci ; an- 

, . n other pus cell gorged 

tions were used. ^ith gonococci ; a 

Infection of the urethra with pus containing gono- group of tree cocci 

1 . alongside ot a nor- 

cocci always produces gonorrhwa, and secretions that do mai pus -cell (Too 

, . . . . . , , . p , . .p diameters). (From 

not contain gonococci are invariably non-miectious 11 Bumm.) 
brought upon the urethral mucous membrane. 

Gonococci have a peculiarly invasive faculty, by which they penetrate 
first the superficial layers of the epithelial membrane, and gradually by 
further proliferation the submucous layer. (Fig. 236). The route of their 



300 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 




Fig. 235. — Vertical section through mu- 
cous membrane, showing first coloni- 
zation of gonococci (700 diameters). 
(From Bumm.) 



inroads is along the intercellular substance. An intense hyperemia of the 
capillaries and other blood-vessels adjoining the seat of the primary infec- 
tion leads to a massive emigration of white blood-corpuscles into the affected 
epithelium. This and the growth of the gonococcal colonies lead to a rapid 

disintegration of the epithelium, which is 
washed away by the lymph-serum in the 
shape of single cells or in coherent epi- 
thelial flakes. Loss of the epithelial in- 
vestment is often followed by the exuda- 
tion of a croupous membrane, beneath 
which clumps of gonococci are to be seen 
in process of active proliferation. Gono- 
cocci can be found occupying at this 
stage the interstices of the subepithelial tissues, their columns extend- 
ing inward along the lymphatics, whence, according to various authors 
(Kammerer), they may be transported to the endocardium, the joints, and 
the synovial sheaths of tendons. 

With the deeper invasion by the gonococci goes pari passu the dense 
infiltration of the in- 
fected tissues with 
leucocytes, the ex- 
tent of which serves 
as a gauge of the in- 
tensity of the infec- 
tious process. 

At the acme of 
the process, general- 
ly reached about the 

end of the second or third week, a regeneration of the lost epithelial layer 
commences. Complete restitution of the epithelium signalizes the termina- 
tion of the malady, which, however, is attained only in favorable cases under 
favorable conditions. Generally primarily unaffected parts of the mucous 
membrane become involved by spontaneous extension of the infective pro- 
cess, or by the improper use 
of instruments ; or portions 
which have recovered suc- 
cumb anew to gonococcal de- 
struction. 

The regeneration of the 
epithelium is always accom- 
panied by hyperplasia, which 
somewhat resembles by its 
tubular formations epitheliomatous mucous membrane (Bumm). These foci 
of epithelial hyperplasia are often coincident with the seat of the most intense 
primary affection. They also correspond with those parts of the submucous 
layer at which the most intense inflammatory infiltration was present. 







% 

Fig. 236. — Invasion of epithelium by gonococci (700 diameters). 
(From Bumm.) 



■ 



v^r 






W: 









# <§&> 



Fig. 237. — Proliferation of gonococci in the epithelium 
(700 diameters). (From Bumm.) 



TKEATMENT OF GONOERHCEA. 301 

As regeneration progresses, the hyperplasia of the mucous membrane 
and the infiltration of the submucous connective tissue disappear by absorp- 
tion. In some cases, however, cicatricial transformation of the neiv-formed 
connective tissue of the submucous layer takes place instead of absorption, 
mid organic stricture develops. 

The transient hyperplastic conditions existing immediately after the 
termination of the gonorrhmal process, and which generally give rise to a 
scanty secretion called gleet, are mistakenly called strictures by various 
authors. 

In contradistinction to stricture, which is a permanent condition, they 
must be declared to be transient stenoses of the urethral caliber, which in 
most cases do disappear without or with the methodical introduction of a 
full-sized bougie or sound. The salutary effect of dilatation upon these 
coarctations of the epithelial and submucous layers is explained by the 
hastening of the absorption of the cellular infiltration by pressure. 

It is true that, if neglected, some of these coarctations will not be ab- 
sorbed, but will become veritable cicatricial strictures. Nevertheless, it is 
an error to declare each and every narroiving of the urethral caliber observed 
shortly after a gonorrheal attack a "stricture of tvide caliber. " The term 
of "incipient stricture" is less objectionable, though often incorrect, as 
many of these "strictures" disappear spontaneously. 

Note. — The presence of various micro-organisms, aside from the gonococcus, in recent and 
chronic urethral discharges, seems to point to the fact that most cases of urethritis represeyit a 
mixed form of bacterial infection. There is no doubt that the inoculation of pyogenic microbes 
into a gonorrhceally affected mucous membrane forms an important element determining the 
intensity and perniciousness of some very bad cases. This assumption is also more in accord- 
ance with the theory of the development of metastases, notably of gonorrhceal rheumatism. 
Bumm is very reserved in regard to the acceptance of Kammercr's investigations, who found 
gonococci in recent effusions produced during an attack of gonorrhoeal rheumatism. On the 
other hand, we know that rheumatic attacks are occasionally provoked by an instrumental 
examination of the urethra of a patient afflicted with " simple " or " catarrhal " or " traumatic" 
urethritis, in which the absence of gonococci is indisputable. Finally, the frequent presence of 
simple pyogenic organisms in rheumatic effusions is generally accepted. It seems, then, that 
pus-generating organisms play an important part in cases of gonorrhceic and non gonorrhceic 
urethritis, and that the metastatic processes complicating urethral inflammations are mostly 
chargeable to their and not to the presence of gonococci. Hence the name " urethral rheuma- 
tism" would be preferable to "gonorrhoeal rheumatism." 



II. TREATMENT OF GONORRKCEA. 

1. Acute Gonorrhoea. Clap. — For practical reasons it will be found 
most convenient to divide the male urethra into two easily distinguished 
parts. 

The first part comprises the anterior portion of the urethra, extending 
from the meatus to the "cut-off muscle," or compressor urethra?, which is 
situated in the membranous portion. All secretions originating in this 
anterior portion of the urethra will readily escape by the meatus into the 
linen of the patient. 
40 



302 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The second or deep portion of the urethra consists of a fraction of the 
membranous part, together with the prostatic portion — in short, of all that 
is situated behind the "cut-off muscle." 

This posterior portion of the urethra is correctly called the neck of the 
Madder, as it forms one cavity with the bladder whenever this becomes 
distended with urine. The internal sphincter alone, unable to resist long, 
yields readily to the pressure of the urine. The voluntary contraction of 
the compressor urethral becomes, then, the only barrier to the escape of the 
urine, and water is voided immediately after the relaxation of this muscle. 

Discharges secreted in the posterior part of the urethra can not escape 
outward past the compressor muscle, and do not appear at the meatus in 
the shape of an external discharge, as those of the anterior urethra. They 
accumulate in the neck of the bladder, and are voided only with the urine, 
which is rendered somewhat turbid by this admixture. 

A very useful practical test for determining the seat of urethral inflam- 
mation is that suggested by Ultzmann. 

The patient is made to pass his water consecutively into two tumblers, 
so that the amount voided should be about evenly distributed in the two 
vessels. Whenever the anterior urethra alone is the seat of inflammation, 
only the first half of the urine will be turbid, or at least will be found con- 
taining flakes and threads ; the second portion will appear perfectly clear. 

In cases of deep-seated urethritis — that is, when the neck of the bladder 
is affected — the first tumbler will receive flaky and turbid urine, and the 
ivater held by the second glass will appear also turbid, but somewhat less so 
than the first portion. 

An additional and most important symptom of the affection of the neck 
of the bladder is frequent micturition, in acute cases accompanied by severe 
spasm and the escape of a small quantity of blood at the end of the act. 
Simultaneously with the severe contraction of the vesical muscles, anal 
tenesmus is observed. 

In every case of recent gonorrhoea the infectious process is confined to 
the anterior urethra, and first to its foremost portion alone. It extends 
from the meatus backward to the compressor urethras, where it generally 
stops. In exceptional cases only does it jDenetrate to the deep urethra, as 
the "cut-off muscle" seems to serve as an effective barrier to its extension 
backward. 

Note. — Forcible urethral injections made from a syringe containing too large a quantity of 
fluid, or the premature introduction of a sound, are frequent causes of the infection of the neck 
of the bladder. 

The seat of the most intense inflammation of the urethra is in its natu- 
rally widest parts — that is, in the fossa naviculars and the sinus bulbi. Here 
we find located the majority of all strictures. 

a. Anterior Gonorrhoeae Urethritis. — The treatment of anterior 
gonorrhceal urethritis should be very discreet in the first invasive stage of 
the disease. It should consist of rest and appropriate general sedative man- 
agement. Locally, cold applications will be found very grateful and effective. 




TKEATMENT OF GONORRHCEA. 303 

As soon as the turbulent first onset has abated, local treatment by dis- 
infectants should commence. Since the cedematous swelling of the parts 
is still prominent, introduction of any instrument for the purpose of irri- 
gation will have to be done with some force. It will cause abrasions of the 
tumid epithelium, and thus will open new portals to gonococcal and pyo- 
genic invasion. Hence irrigation at this period is to be condemned. 

Urethral injections, on the other hand, done with a properly shaped 
syringe of moderate capacity, are very useful. Sigmund's syringe, hav- 
ing a blunt conical nozzle, is an appropriate instrument. It holds three 
eighths of an ounce 
of fluid, which quan- 
titv is sufficient. 
(Fig. 238.) 

The Strength of Fig. 238.— Sigmund's urethral syringe. 

the solutions em- 
ployed should also be determined by the intensity of the local symptoms. 
Strong solutions will cause intense smarting, and on that account the injec- 
tions will not be made frequently enough by the patient. In very sensitive 
cases an entirely unirritant tepid solution of salt water (6:1,000, or a tea- 
spoonful to a quart) can be employed with much benefit. As the symptoms 
abate, sulphocarbolate of zinc (fifteen grains to six ounces), or permanganate 
of potash (one grain to six ounces), can be substituted for the saline solution. 

The main object of these first injections is the cleansing of the urethra ; 
hence the injections must be made frequently, at least six times in a day, or 
oftener. Each injection should be preceded by urination, and should be 
a double one — the first syringeful to wash out the pus ; the second syringe- 
ful to act upon the mucous membrane. This second injection should be 
retained in the urethra for two minutes. The strength of the injections 
should be increased pari passu with the abatement in the acuity of the local 
symptoms, but the solutions should never be made corrosive. 

Every patient should receive practical instruction from the physician 
regarding the proper manner of injecting. 

Note. — The author saw a case of chronic gonorrhoea that had successively passed through 
the hands of three colleagues, none of whom convinced himself whether the patient was making 
the injections properly or not. Phimosis was present, and the patient was in the belief that 
the injections had to be made under the prepuce. No wonder his clap had remained uninflu- 
enced by this treatment. 

In the later stages of acute gonorrhoea irrigation of the anterior urethra 
will be found a very satisfactory and effective mode of treatment. It should 
be done by the physician himself at least once daily, or as often as possible, 
in the following manner : 

A pint bowl is filled with tepid water. To this is added enough con- 
centrated solution of permanganate of potash to color the water to the hue 
of light claret. A straight or slightly beaked female catheter of metal (Fig. 
239), five inches in length (No. 8 English caliber), is lubricated with glyc- 
erin, and is introduced as far as the compressor-urethrse muscle. When- 




304: RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

ever the beak of the instrument comes in contact with the muscle this will 
contract, and will resist further introduction. The patient stands in front 
of the sitting physician, and is made to hold a pus-basin or tin pan under 

his scrotum and penis. The 
physician fills with the solution 
a hand-syringe holding four or 
five ounces, and injects the fluid 

Fig. 239. — Short metallic catheter tor irrigation of " 

anterior urethra. through the catheter into the 

urethra, whence it will readily 
escape by the meatus into the pus-basin. This is repeated until the solu- 
tion is exhausted. Irrigation should be preceded by micturition. 

With proper diet and regime, ordinary cases of gonorrhoea will be cured 
by this treatment in from three to six weeks. 

Note. — To prevent soiling of the patient's linen by profuse urethral discharges, the follow- 
ing simple arrangement will be found effective and convenient. A child's sock is fastened with 
a safety-pin to the interior of the skirt of the patient's undershirt. In the toe of the sock is 
thrust a small ball of cotton, which is then drawn over the penis, and is held there by the sock. 
Whenever occasion permits, the soiled cotton is replaced by clean material, and thus no tell- 
tale blotches will be made on shirt and drawers. 

b. Deep-seated Gonorrhceal Urethritis. — Spontaneous extension 
of gonorrhoeal infection beyond the cut-off muscle to the posterior part of 
the urethra is a comparatively rare occurrence. More frequently infection 
is carried to the deep urethra by too large injections or the premature inser- 
tion of sounds. As long as in a case of anterior gonorrhoea the discharges 
are profuse and creamy, and the mouth of the urethra oedematous and red, 
no sound should ever be passed. 

Infection of the deep urethra invariably provokes an unmistakable com- 
plex of symptoms — namely, frequent urination, which is followed at its 
termination by a violent spasmodic pain and the escape of some bloody 
urine or a few drops of pure blood. 

Ordinary injections, or even irrigations of the urethra as above described, 
are utterly unable to reach and to influence the course of deep-seated gon- 
orrhoea. To cleanse and disinfect the diseased part, an efficient germicidal 
solution must be brought exactly in contact with the morbid mucous mem- 
brane of the posterior urethra. If we inject a solution into the bladder, its 
chemical properties will be at once destroyed by the admixture of urine, 
hence means must be found by which we can make the unchanged solution 
come in contact with the seat of the disease. For this purpose TJltzmanrfs 
method of irrigating the_neck of the bladder will be found very effective. 

As soon as the most acute invasive stage of the affection shall have be- 
come mitigated by rest, sedatives, balsamics, and proper diet — that is, in about 
the third or fourth week — a quart of a mild, tepid solution of permanganate 
of potash (1 : 5,000) is prepared. A not too small-sized soft gum (Nelaton's) 
catheter (Fig. 240) is lubricated with glycerin, and is introduced as far as 
the compressor-urethrae muscle. A hand-syringe holding about four ounces 
of fluid is filled with the solution, which is then injected into the catheter, 



TEEATMENT OF GONOEEHCEA. 



305 



and will be seen escaping from the meatus alongside of the instrument. 
After this preliminary washing of the anterior urethra, the patient is di- 
rected to assume the recumbent posture. The soft catheter is again lubri- 
cated, and is passed gently into the bladder. This process will be very 
much facilitated by the injection of a small quantity of glycerin through 
the catheter when it is about to pass the cut-off muscle. A small amount 
of pressure will overcome the tension of the compressor, and the arrival of 
the point of the instrument in the desired locality can be tested by injecting 
an ounce or two of the prepared lotion. Should it escape from the urethra, 
this would be a sign that the eye of the catheter has not passed the com- 




Fig. 240. — Nelaton's soft gum catheter. 



pressor muscle. If, on removal of the syringe, the lotion is seen to escape 
at once from the bladder through the catheter, then it may be concluded 
that the eye of the catheter is in the cavity of the bladder, and that it has 
been introduced too far, and needs to be withdrawn an inch or a little more 
or less. Should, on renewed injection, the lotion all enter the bladder, but 
fail to escape through the catheter, this is a positive sign that the beak of 
the instrument is just beyond the cut-off muscle — that is, in the posterior 
part of the membranous portion. Fluids injected into this place will readily 
enter the bladder, as their pressure can easily overcome the internal sphinc- 
ter; but recontraction of this muscle will prevent their escape until the 
beak of the instrument is pushed into the vesical cavity. According to the 
irritability of the patient, from one to four ounces of the lotion are slowly 
injected while the point of the catheter is located in the space between the 
cut-off and internal sphincter muscles. As soon as the patient complains 
of pressure, injection should cease, and the catheter should be gently pushed 
within the vesical cavity, whence it will at once conduct the injected fluid 
into a vessel placed between the thighs of the patient. It is better not to 
inject too large a quantity at the beginning, as this is liable to bring on 
vesical spasm, resulting in a violent and irresistible expulsion both of lotion 
and catheter. 



306 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

The injections are to be repeated in this manner until the lotion is seen 
to return clear from the bladder. The final injection is voluntarily passed 
by the patient. This is to satisfy him that his bladder is empty, and that 
the sensation of the desire to urinate is not caused by retained fluid. 

The improvement following this procedure is very apparent, though not 
lasting, and daily repetition will be necessary until the frequency of mic- 
turition will have been very materially reduced. 

The author has never seen any untoward consequences following this 
gentle and very efficient mode of treating deep-seated urethral gonorrhoea. 
The danger of cystitis or inflammation of the testicle will be rather abated 
than increased by this treatment if it be carried out properly and without 
violence. The possibility of performing the entire procedure without any 
abrasion, undue pressure, or injury of the inflamed parts, ranks it high 
above all measures in which unyielding sounds, catheters, or caustic holders 
are placed in the neck of the bladder for purposes of cauterization. Their 
use is often followed by epididymitis, and is deservedly held in bad repute. 

Where the affection extends over the whole urethra, treatment of the 

neck of the bladder and of the anterior urethra can and ought to be carried 

out simultaneously until the secretion escaping from the meatus be reduced 

to a minimum, and until the frequent urgency to urinate and the turbidity 

of the water give way to a marked extent. 

Gonorrhoea! catarrh of the neck of the Madder should not he 
mistaken for acute cystitis. Pus will be found in the urine in 





Fig. 241. — Ultzmann's prostatic syringe. 

both cases, but in cystitis febrile disturbances accompanied by alteration of 
the general health will be observed, and pressure pain above the symphysis 
pubis will be noted aside from the periodical pain located in the perineal 
region, which follows urination, and which is the diagnostic sign of the 

affection of the 

deep urethra only. 

Should irriffa- 





urethra not effect 

Fig. 242. — Keyes's modification of Ultzmann's deep urethral syringe. " " 

cessation of the 
affection, instillation of a few drops of a five-per-cent solution of nitrate of 
silver will be found very beneficial. This is done by Nelaton's catheter or 
Ultzmann's deep urethral syringe. (Figs. 241 and 242.) The point of the 
filled instrument is dipped in glycerin, and is gently introduced just within 
the compressor-urethrae muscle. When the barrel of the syringe is at an 
angle of forty-five degrees with the body of the recumbent patient, its beak 
is just within the neck of the bladder. Three, four, or five drops of the 
nitrate-of -silver solution are expelled from the syringe, and enter the deep 



TREATMENT OF GONORRHOEA. 



307 




urethra. Intense smarting and spasm of the neck of the bladder follow the 
injection, but soon disappear if the patient retain the reclining posture for 
a short while. 

These deep injections of nitrate of silver are a very effective though 
painful means of checking a gonorrhoea! inflammation of the deep urethra, 
and deserve more frequent employment than they receive at present. The 
procedure does not entail any danger, and is rather a preventive than a 
cause of epididymitis or cystitis. 

2. Chronic Gonorrhoea. Gleet : 

a. inflammatory stenosis (incipient stricture) and 
Permanent or Cicatricial Stricture of the Urethra : 

(a) Anterior Urethra. — The termination of acute gonor- 
rhoea is never abrupt. It is always inaugurated by a period 
characterized by the escape of a scanty amount of purulent 
discharge. During this period subacute attacks or relapses 
of the affection may be precipitated by any cause inducing 
hyperaemia of the urethral mucous membrane. Sexual irrita- 
tion, alcoholic indulgence, severe bodily exercise, offer mainly 
occasions for this occurrence. 

When an acute gonorrhoea has reached this stage, the prog- 
ress of the recovery often seems to suffer a halt, due princi- 
pally to secondary hyperplastic changes of the mucous and 
submucous tissues. The daily introduction of a full-sized 
sound or bougie for a week or two is generally sufficient to 
produce rapid absorption of the interstitial exudation and a 
permanent cure. 

A contracted meatus is an effective impediment to the 
application of the sound, and requires an adequate division 
of the narrow urethral orifice. Meatotomy, however, should 
never be carried too far, its only object being the easy admis- 
sion of a full-sized steel sound. It is made with a blunt- 
pointed tenotomy knife, and the haemorrhage caused by it 
can be easily checked by the introduction of a small pledget 
of iodoformed gauze into the slit. 

Should the patient positively decline meatotomy, blunt 
dilatation of the part of the urethra, which is the seat of the 
inflammatory swelling and contraction, can be done by Otis's 
urethrometer. (Fig. 243.) The closed instrument is intro- 
duced beyond the coarctation, then it is opened until the dial 
indicates that the bulb has been dilated to full caliber, and 
then it is drawn with some force through the narrowed portion of the 
urethra. The author has seen very good results follow this use of Otis's 
instrument, though the procedure does not deserve preference over mea- 
totomy and dilatation by the steel sound. 

The absorption and disappearance of these "incipient strictures" is very 
much hastened by the local application of a strong (five-per-cent) solution 



308 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

of nitrate of silver. To enable an exact application of the caustic under the 
guidance of the eye, the endoscope must he used. 

The endoscope is a cylindrical silver tube of from four to six inches in 
length, and of various calibers. (Fig. 244.) An obturator facilitates its 
painless introduction, and a flange or shield made of hard rubber, having a 
"dead finish," permits an easy handling of the instrument. Strong arti- 
ficial light or sunlight is needed for endoscopy. The patient reclines on a 
tall chair, or sits on the edge of a table, his back supported by a suitable 
rest, the examiner occupying the space between the patient's legs. To pro- 
tect the patient's clothing against soiling with blood or chemicals, a piece 
of rubber cloth (eighteen inches square), provided with a small central slit 
just long enough to permit the slipping through of the penis, is spread on 
the pubic region. Thus the only object exposed to view will be the patient's 




Fig. 244. — Klotz's urethral endoscope. 

penis. Over the rubber cloth a clean towel is laid for wiping off fingers, 
etc. A basin containing a number of slender match-sticks, their ends 
armed with tufts of absorbent cotton, is at hand, and a pus-basin is next to 
it, to receive the soiled sticks. On a little table adjoining the operating- 
chair are a small, wide-mouthed bottle of glycerin and a few glass salt- 
cellars or hour-glasses for the reception of such solutions as may be required. 
Of these the author uses two — a five-per-cent solution of nitrate of silver 
and a ten-per-cent solution of the same substance, both in dark bottles. 

An endoscopic tube of suitable size being selected, it is lubricated with 
a little glycerin, and is introduced well into the bulbous portion of the ure- 
thra. The obturator is withdrawn, and the surgeon by his head-mirror 
directs a ray of sun- or lamp-light into the bottom of the tube, where the 
mucous membrane of the urethra is visible in the shape of a typical image, 
consisting of several concentric folds uniting to a central, funnel-shaped 
depression. 

In sunlight the normal mucous membrane is pale, of about the same hue 
as the normal buccal lining, and on it are visible a number of delicate trac- 
ings, produced by minute vessels. It is very smooth and glossy, and the 
folds of the image are flexible and rather delicate, and present no change of 
color on deeper introduction or withdrawal of the tube. 

Inflamed urethral show an entirely different aspect. The most delicate 
manner of introducing the instrument is apt to cause slight haemorrhage, 
which sometimes is very troublesome, as the blood fills up the tube faster 
than it can be mopped away, frustrating for the time being all further 
manipulation. When the mucous membrane, exposed in the bottom of the 
endoscope, is dried off with a pledget of cotton, it has a dull, dead gloss, 




TREATMENT OF GONORRHCEA. 309 

or velvety appearance ; it shows a more or less intense, uniform shade of 
red, scarlet, or pnrple. The folds of the endoscopic image are few and 
coarse, and not so flexible as those of the normal urethra. 

Gradually withdrawing the tube with short stops, the entire length of 
the urethra can be thus inspected. 

In chronic gonorrhceal urethritis the inflammation will be found limited 
to more or less well-circumscribed portions of the urethra. These parts, 
examined by urethrometer or bulbous bougie, quite frequently show a well- 
marked though moderate contraction, which can also be demonstrated to 
the eye through the endoscope. 

In withdrawing the tube, new parts of either normal or uniformly red, 
inflamed mucous membrane will present themselves to the examiner's eye. 
Suddenly, however, the field of vision will become pale, perfectly ancemic, 
and ivory-colored. This change of color is 
due to depletion of blood and the anaemia of 
the constricted part of the urethra, caused 
by the distention produced by the dilating Fig 245t _ Metallic ^W^e. 
instrument. As soon as the end of the tube 

is withdrawn from the stenosed part, the formerly bloodless tissues are seen 
to suddenly flush up and become of exactly the same color as the rest of the 
inflamed mucous membrane. Examination by the bulbous bougie (Fig. 245) 
will show that the seat of this phenomenon corresponds exactly with the 
locality of the narrowing of the urethral caliber. 

In cases where gleet has persisted for several months, these constricted 
places appear in the endoscope of a pearly color, which is due to the con- 
siderable thickening of the epithelial layer. 

The application of the nitrate-of-silver solution to these ' ' incipient strict- 
ures" will be found to materially hasten their absorption, if it be supple- 
mented by the introduction of a full-sized sound. The applications are 
made through the endoscope every other day with a camel's-hair brush or a 
wad of absorbent cotton fastened to the end of a long match-stick. They 
cause a slight smarting, which does not persist very long. Occasionally 
they are followed by slight haemorrhage on the day subsequent to the appli- 
cation, which, however, is without any significance. 

Most of these "incipient strictures" get well under the treatment just 
described, and do not require urethrotomy. 

But, when the embryonic connective tissue of these stenoses of inflam- 
matory character becomes definitely transformed into fibrillar connective 
tissue — that is, a fully developed cicatrix — it represents a permanent — that 
is, organic — stricture that can not be cured by simple dilatation and topical 
applications. True, it may be gradually dilated to the normal caliber, but 
the dilatation will be evanescent, and speedy recontraction will follow the 
cessation of the treatment. 

The appearance of a cicatricial or permanent stricture in the endoscopic 
field of vision differs in many ways from that of an inflammatory stenosis. 
This diagnostic distinction is all the more valuable, as an examination by 
41 



310 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

the bulbous bougie, although capable of demonstrating the presence of a 
narrowing of the urethral caliber, does not divulge anything regarding the 
nature of the stenosis. 

The most characteristic feature of permanent strictures is the unchang- 
ing anaemic, pale condition of the mucous membrane about the stricture 
in the endoscopic field of vision. The sudden flushing up on withdrawal 
of the endoscopic tube, seen in the contractions of recent date, is absent. 
The second characteristic is the peculiar rigidity of the urethral wall at 
the site of the stricture. On withdrawing the endoscope, the rigid walls 
of the urethra show a tendency to remain patulous, so that, instead of a 
small and rapidly changing image of soft, pliable mucous membrane, a 
comparatively long stretch of the urethra can be looked over at a glance, 
resembling somewhat the walls of a short tunnel. 

Absorption and disappearance of a cicatricial stricture are a very excep- 
tional occurrence, whether it be subjected to treatment or not. To suffi- 
ciently widen a strictured urethra, urethrotomy, followed by methodical 
dilatation, is required. 

Such a cure as is not infrequently observed to come from treatment of 
an inflammatory stenosis — that is, a perfect restitution of the normal state 
of affairs — is never to be expected after the treatment of a cicatricial stricture, 
be this treatment dilatation alone, or cutting combined with subsequent dila- 
tation. The cicatricial ring will become wider than before, but its rigidity 
and unnatural appearance will remain unchanged. 

The cases in which the cicatricial bands can be divided in their entirety 
yield the comparatively best results. But the worst strictures involve the 
entire thickness of the spongy part of the urethra, and to effect complete 
division in these cases the entire thickness of the urethra would have to be 
cut through, which is an impracticable and sometimes dangerous procedure. 

Case. — M. F., aged forty-two, had a series of old cicatricial strictures involving the 
entire anterior portion of the urethra. One seated in the fossa navicularis was very 
tight, another one at the bulbo-membranous junction was very massive, so that it 
could be felt through the perinseum. Blunt dilatation with steel sounds, up to No. 34 
of the French scale, always produced cessation of the profuse discharge, but, recontrac- 
tion to the old condition always following within forty-eight hours, internal ure- 
throtomy was decided on. August 20, 1885. — The operation was performed with Otis's 
urethrotome. The urethra was dilated to No. 30, and then two parallel incisions were 
made along the entire length of the roof of the pendulous portion. Some hesitation 
of the bulbous bougie was noted at the bulbo-membranous junction, therefore Otis's 
instrument was reintroduced, dilated to No. 32, and the still narrow part of the urethra 
once more cut. Smart haemorrhage was observed, but not more than the length of 
the incision justified, and after some compression it ceased. On returning to the pa- 
tient after the lapse of two hours, the writer found him lying on his blood-soaked 
mattress in a pool of blood, in a most deplorable state of prostration and anxiety. The 
scrotum and penis were swollen out of proportion, and had assumed a blue-black color, 
and blood was issuing from the meatus at varying intervals. A large English web- 
catheter was introduced and tied into the bladder, and only persistent digital pressure 
exerted over the bulbous portion for more than two hours succeeded in arresting the 



TREATMENT OF GONORRHCEA. 



311 



loss of blood, and checked further bloody infiltration of the penile and scrotal tissues. 
Fortunately, infection of the wound was avoided by careful asepsis, and thus, no fever 
and inflammation following, the entire enormous extravasation was readily absorbed. 
Introduction of large sounds was commenced on the twelfth day, and after a some- 
what prolonged convalescence the patient recovered. With the regular use of the full- 
sized steel sound, and an occasional irrigation 
of the neck of the bladder, the patient suc- 
ceeds in maintaining a very comfortable state 
of health. 

In the case just related, complete di- 
vision of the posterior stricture, situated 
at the bulbo -membranous junction, led to 
the injury of the bulbar artery, imbedded 
in the cicatricial mass constituting the 
stricture. Had the wound been infected 
by the use of uncleanly instruments, sup- 
puration and decomposition of the large 
bloody infiltration might have brought 
the patient into very great danger. 

A serious objection to Otis's. otherwise 
excellent urethrotome (Fig. 246) is the 
great difficulty of thoroughly cleansing 
the complicated instrument. 

The author recommends the following 
simplified manner of performing inter- 
nal urethrotomy of the anterior urethra 
for strictures of wide caliber. A long 
and stout-shanked, rather narrow-bladed, 
blunt-pointed tenotomy-knife is first in- 
troduced well beyond the ascertained 
depth of the stricture. Alongside of 
this, Otis's urethrometer is inserted to 
the same depth. The bulb of the latter 
instrument, being well dilated, is drawn 
forward until it is arrested by the strict- 
ure. While the bulb of the urethrome- 
ter is held close to the mesial entrance 
of the stricture, the tenotomy-knife is 
grasped and its sharp edge is applied to 
the tense cicatricial bands. It is drawn 
forward until the blade is past the con- 
striction. Should the bulb of the ure- 
thrometer follow without a halt, the stricture can be considered as suffi- 
ciently divided ; should the division be insufficient, the bulb of the ure- 
thrometer is closed, and the tenotomy-knife is slipped back past the stricture 
to repeat the process of cutting. Thus the surgeon is sure of dividing only 




312 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



the stricture, and not cutting deeper than necessary to permit the passage 
of the dilated bulb. The method is both simple and exact, and seems well 
deserving of trial. 

For very tight strictures Maisonneuve's instrument is most proper. 
(Fig. 247.) 

Careful disinfection of the surgeon's hands and instruments, and irri- 
gation of the urethra with a watery tepid solution of permanganate of pot- 
ash (1 : 2.000), should precede every step or oper- 
ation that may lead to wounding of the urethral 
mucous membrane. As a lubricant, iodoformized 
vaseline (1 : 30) should be used. The operation 
should terminate with a renewed irrigation of the 
urethra. 

Whenever strictures are cut that have their seat 
near the bulbo-membranous junction, a new, large- 
sized, English elastic catheter should be tied into 
the bladder for twelve hours, and the patient should 
be kept in bed for a day or two. These precautions 
are rarely necessary in cutting strictures located in 
the pendulous portion, as it is not difficult to pre- 
vent haemorrhage by the application of a compres- 
sory bandage to the penis. A gutter of light paste- 
board is applied to the under side of the penis, 
which is first enveloped in a layer of cotton, and 
the splint is firmly secured by a few turns of a roller 
bandage. The penis and scrotum are held up to 
the belly by a snugly fitting T-bandage. This pre- 
ventive appliance can be abandoned on the second 
day after the operation. 

If ammoniacal urine be present, its condition 
«! should be influenced before operation by the in- 

ternal administration of boracic acid, benzoate of 
soda, lactic acid, or turpentine, so as to become at 
least of neutral, or what is still better of acid, re- 
action. 

A full-sized steel sound is to be introduced twice 
weekly, the first application not to commence before 
the fifth or seventh day after the operation. Much 
pain to the patient will be avoided by first intro- 
ducing a copiously anointed smaller- sized sound, 
which will carry a good deal of the lubricant into 
the urethra, and will render the subsequent use of a full-sized instrument 
comparatively painless and easy. 

With the precautions above described, the author has not observed a case 
of urethral fever following either internal urethrotomy or the use of dilat- 
ing instruments in the urethra. His experience extends over twenty-one 




TREATMENT OF GONORRHOEA. 313 

cases, in which strictures were cut successfully from within. No febrile or 
inflammatory complications were ever observed. 

(b) Deep Urethral Strictures. — Strictures of the deep urethra are located 
in the membranous portion. Their development is preceded by a stage 
of epithelial and submucous hyperplasia, identical with the process observed 
in the anterior urethra. This hyperplastic condition is amenable to suc- 
cessful treatment by dilatation and caustics, but unheeded, will develop 
into permanent stricture. 

Internal urethrotomy of a deep-seated stricture is a much more grave 
undertaking than the cutting of a stricture of the anterior urethra. Both 
the danger of haemorrhage and the difficulty of controlling it, should it 
occur, render the operation serious. Haemorrhage from the posterior part 
of the urethra, lying behind the "cut-off" muscle, may long remain un- 
recognized on account of the absence of free bleeding from the meatus, as 
the escaping blood will flow back into the bladder, and can be expelled only 
with the urine. For these reasons treatment by gradual dilatation should 
be carried on whenever possible, and urethrotomy should be reserved for 
cases only that do not yield to dilatation after patient trial, or will not 
brook delay. When an operation is decided on as necessary, external ure- 
throtomy deserves the preference over the internal operation, especially in 
cases complicated by ammoniacal cystitis. Haemorrhage will be easy to 
control. The good drainage resulting from the external incision will pre- 
vent urine infiltration, and ready access to the bladder will facilitate anti- 
septic irrigations of the organ. 

External Urethrotomy. — The anaesthetized patient is brought in the 
lithotomy position, his hands being bandaged to the feet, which are then 
wrapped in clean towels, wrung out of corrosive-sublimate lotion. The 
perinaeum and anal region being shaved and rubbed on* with the same 
lotion, the operation begins. Irrigation of the wound by Thiersch's solu- 
tion is carried on during the entire operation. When a staff or even a fili- 
form bougie can be carried into the bladder to serve as a guide, the opera- 
tion will offer no difficulty whatever. As soon as the urethra is opened and 
the stricture exposed, its division can be accomplished by the use of a blunt- 
pointed tenotomy knife. External urethrotomy without a guide is not as 
easy, but its difficulties can be overcome by patience and circumspection. 

While an assistant exerts gentle pressure over the distended bladder, the 
bottom of the urethral wound being well exposed by small, sharp retractors 
or fillets of silk drawn through the lips of the urethral incision, one or two 
drops of urine will be seen exuding from one or another point of the strict- 
ure. A fine probe is inserted into the point in question, and will often 
penetrate the stricture. A nairow, grooved director is insinuated along the 
probe, and serves to guide a sharp-pointed tenotomy knife through the con- 
traction, which then can be divided without difficulty. 

Should this expedient fail, on account of inflammatory swelling of the 
tight part of the urethra, suprapubic aspiration of the bladder may serve to 
tide over the difficulty. Relief of the distention of the bladder is often fol- 



814 EULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

lowed by decrease of the swelling, and a few hours after the operation urine 
will be found escaping through the urethra, when the true channel can be 
searched out and dilated. 

Case. — N. S., laborer, aged 42, impermeable stricture of the membranous portion 
of the urethra. March 11, 1883. — External urethrotomy without guide. The stricture 
being exposed, most diligent search failed to ascertain the direction of the channel, 
which was obscured by the intumescence and great vascularity of the parts. The dis- 
tended bladder was finally emptied by suprabubic aspiration, and the patient was 
brought to bed. Six hours later the bladder had refilled, and urine was seen to trickle 
from the wound whenever the patient strained. Renewed search was rewarded by 
the finding of the right track, which was divided on the grooved director without 
much trouble or pain to the patient. May 20th. — Patient was discharged cured. 

A modification of another expedient, proposed by the venerable Petit, 
was also successfully employed by the writer. 

Case. — John Smith, negro hostler, aged 31, suffered from impermeable stricture 
of the deep urethra with dangerous distension of the bladder. The usual expedients 
for entering the bladder having failed, external urethrotomy was determined upon, 
and was carried out December 2, 1876. The distal part of the stricture being exposed, 
no entrance could be effected. As there was no aspirating needle on hand, a slender 
trocar was inserted into the middle of the strictural mass, and was pushed forward in 
the direction of the urethra, toward the center of the prostate, under the guidance of 
the left index -finger placed in the rectum. The point of the instrument was several 
times caught in the mass of the prostatic gland, but finally entered the median canal 
and the bladder, this being attested by the escape of urine. A grooved director was 
pushed in along the cannula, which was withdrawn, and the stricture was divided 
with a tenotomy knife. A sharp attack of fever and cystitis followed, but the patient 
fully recovered and was discharged cured March 5, 1877. 

Strictures located in the anterior urethra can be simultaneously divided 
by Otis's urethrotome or the tenotomy knife before the patient recovers 
from the anaesthetic. The bladder is then washed out with Thiersch's 
solution, and the wound is dressed with a pad of iodoformed and a compress 
of sublimated gauze, held in place by a T-bandage. In the presence of 
fetid urine, the use of a drainage-tube is advisable. Before applying the 
dressings the wound should be rubbed out with a small sponge dipped in 
iodoform powder. Anointing of the perinaeum and buttocks with vaseline 
is necessary to prevent eczema. The external dressings ought to be changed 
whenever soaked ; the iodoformed pads, however, should not be disturbed 
without necessity as long as they are adherent. Daily sitz-baths in a weak 
(1 : 10,000) corrosive-sublimate solution will tend to increase the comfort 
of the patient, and will aid the healing of the w T ound. 

The daily introduction of a full-sized steel sound need not be commenced 
before the seventh day, and should be continued at increasing intervals for 
at least a year after the operation. 

Altogether, the author jDerformed external urethrotomy seventeen times. 
Fifteen patients recovered, two died. The fatal cases were as follows : 

Case I. — Mr. S. O., tailor, fifty-four years old, suffering from tight, deep-seated 
stricture of the urethra, complicated with purulent and fetid pyelo-nephritis. The 



TREATMENT OF GONORRHOEA. 315 

urine remained ammoniacal, and the fistula never closed. He died, August 5, 1886, of 
uraemia, five months after the operation, done March 25, 1886. 

Case II. — Abraham Goldfish, aged seventy-seven, suffering from deep-seated ure- 
thral stricture, fetid cystitis, and extensive urine infiltration of the perinseum, due to a 
false passage made by a physician. External urethrotomy was performed, November 
1, 1886, at Mount Sinai Hospital, with much relief of the subjective symptoms, but 
the patient succumbed to septicaemia and septic nephritis on November 18, 1886. 

Of the remaining cases, one deserves special mention on account of its 
rarity : 

Case. — S. E., shopkeeper, aged sixty-three, sustained, in 1875, a compound fracture 
of the left horizontal ramus of the os pubis, from which he recovered after a long term 
of illness. In the spring of 1882 increasing difficulty of micturition became noticeable, 
and finally led to retention of urine. June 25, 1882. — The author saw the case in con- 
sultation with Dr. I. Schnetter. A metallic sound could be passed easily as far as the 
membranous portion, but was there arrested by a grating, hard body, thought to be a 
sequestrum or a stone. External urethrotomy was done June 27th, and an irregularly 
shaped sequestrum, one inch long and one sixth of an inch thick, was withdrawn with 
some difficulty. Patient recovered without fistula, and was cured in about six weeks. 

b. Vegetations of the Ueethka. — Venereal vegetations, such as are 
frequently observed under the prepuce of men suffering from gleet, occa- 
sionally occur in the urethra, principally in the fossa navicularis and in 
the sinus bulbi. They maintain a rebellious urethral discharge that can be 
stopped only by their removal. Their diagnosis can be made by the aid of 
the endoscope, which also affords the best means of access for their treat- 
ment. The use of the curette, or a small wire snare, or of chromic acid in 
crystals, will readily destroy them, and will terminate the urethral discharge 
depending on their presence. 

c. Granular Urethritis. — One of the most tedious affections of the 
urethra is a chronic inflammation of the mucous membrane following an 
attack of acute gonorrhoea, characterized by an irregularly distributed hyper- 
emia and scanty discharge. The velvety mucous membrane bleeds at the 
slightest touch, and the condition resists every form of local treatment for 
a disproportionately long time. It seems that the intractability of this 
affection depends in a great measure upon constitutional disorders ; at least 
the author observed it most frequently in anaemic individuals of a scrofulous 
habit. Measures directed to the improvement of the general condition, and 
supplemented by the local application of a five-per-cent solution of nitrate 
of silver by the endoscope, seem to have been more efficient than anything 
else, though it must be admitted that a few cases resisted every kind of 
treatment, and had to be given up as entirely unmanageable. 

d. Chronic Catarrh of the Posterior Part of the Urethra, 
and Chronic Cystitis. — Chronic catarrh of the membranous and prostatic 
part of the urethra is frequently observed following an acute attack of gon- 
orrhoea, in subjects formerly addicted to masturbation, or those indulging 
in general, and especially in sexual, excesses. In these cases no external 
urethral discharge is visible, but frequent micturition is present, and both 



316 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

portions of the urine, passed into two tumblers, show turbidity, the first 
portion, however, being more turbid than the last. 

Treatment by gradual dilatation with full-sized sounds is perfectly use- 
less in this affection, and may even lead to epididymitis in some cases. 
Methodical irrigation of the neck of the bladder, on the other hand, by means 
of a soft gum catheter and hand syringe, as described in a preceding para- 
graph, will be very often found beneficial. Of all substances, a 1 : 2,000 
tepid solution of permanganate of potash has been found most generally 
applicable. A quart china bowl is filled with warm water, and enough of a 
concentrated solution of the salt is added to tinge the water a light-claret 
color. This test, by observing the depth of the tinction, is very sensitive 
if applied to weak solutions, and commends itself by its simplicity. Next 
to permanganate of potash, one-per-cent solutions of sulpho-carbolate of 
zinc or of acetate of lead deserve mention. But nitrate of silver is the 
most efficient of all known remedies in obstinate cases of chronic deep-seated 
urethritis or prostatic catarrh. A few drops of a five-per-cent solution are 
instilled, twice or three times a week, by Ultzmann's or Keyes's deep ure- 
thral syringe, as formerly described. 

Acute cystitis, whether gonorrhceal or pyogenic, is not amenable to in- 
strumented treatment, ivhich should only commence after the cessation of the 
invasive stage. The object of medicinal irrigation is the disinfection and 
removal of fermenting urine and its decomposed contents, such as ropy 
mucus, blood, and pus. 

If stone or a stricture be the causative agents, they must be removed ; if 
imperfect evacuation of the bladder, on account of paresis, or enlargement 
of the prostate, is at the bottom of the trouble, regulated evacuation of the 
organ by catheterism must be employed. Aside from fulfilling these causal 
indications, recovery can be materially hastened by methodical irrigation. 

Irrigation with a metallic "double current" catheter, as recommended by 
various authors, is unsatisfactory. Inxroduction of the rigid catheter is 
painful, and may be the source of various complications. The advantages 
of the double current are illusory, as much of the ropy mucus and other 
sediment found in the cul-de-sac of the bladder is not brought out by its 
use. A more gentle and much more efficient way of thoroughly emptying 
the deleterious contents of the inflamed bladder is as follows : 

The patient is made to stand before the seated physician. This position 
is more favorable than any other, as in it the sedimental matter contained 
in the urine is made to gravitate toward the neck of the bladder, where it 
is readily stirred up and evenly distributed in the urine by the injections. 
Thus it will pass the catheter much easier than when it forms a sticky mass. 
A soft rubber catheter is introduced into the bladder, and a hand-syringeful 
of a tepid, weak solution of cooking-salt (one teaspoonful to a quart, about 
6 : 1,000) is thrown in gently, and is allowed to escape at once. This is 
repeated until the returning saline solution is clear and limpid. After this, 
two or four ounces of a tepid 1 : 5,000 solution of permanganate of potash 
are injected and retained for one or two minutes, and the process is repeated 



TREATMENT OF GONORRHOEA. 317 

until the returning fluid ceases to be discolored. By and by, as the bladder 
becomes more tolerant, the injection should be made more forcible, as a 
thorough stirring up and dislodgment of the ropy sediment by the jet of 
lotion is very essential to its complete evacuation. The strength of the 
medicinal lotion should also be gradually increased (to 1 : 1,000). 

In cases of paresis, or when a tendency to vesical haemorrhages be pres- 
ent, cold, instead of tepid, injections will be appropriate. 

In obstiuate catarrh the strength of the permanganate-of-potash lotion 
can be increased to 3 : 1,000. Alum (from 1 : 100 to 5 : 100), sulphate of 
zinc (from 1 : 100 to 2 : 100), and nitrate of silver (from \ : 100 to 2 : 100), 
will also be found very effective. Deodorization of fetid urine is readily 
effected by injections of a 3 : 100 solution of resorcine. which should be 
followed up by the employment of one or another of the medicinal solutions 
above mentioned (Ultzmann). 

If the capacity of the bladder be very much diminished by long-con- 
tinued spastic contraction accompanying gonorrhceal or calculous cystitis, 
gentle and gradual distention of the organ by salt water or medicinal in- 
jections of increasing volume will be followed by increasing tolerance. 
Thus micturition will gradually become less frequent, and the normal con- 
dition of things may be re-established. 

Xote. — Gradual distention of the shrunken bladder of elderly persons is dangerous, as it 

may lead to rupture of diverticula. 



42 



PART V. 



SYPHILIS : 

ASEPTIC AND ANTISEPTIC TREATMENT 
OE ITS EXTERNAL LESICNS. 



CHAPTER X. 

ASEPTICS AND ANTISEPTICS APPLIED TO EXTERNAL SYPHILITIC 

LESIONS. 

1. Aseptic Treatment of Primary Induration. — The nature of the specific 
virus of syphilis is not known. In most cases its local and general mani- 
festations are amenable to appropriate systemic and topical remedies. 

It is not intended here to dwell upon the nature and treatment of 
syphilis as a general disease ; only inasmuch as some of its more common 
local phenomena require surgical treatment will their consideration be 
deemed within the limits of this chapter. 

The anatomical structure of the primary induration, of tuberous syphi- 
lides, and of gummy swellings, resembles closely that of recent tuberculous 
deposits ; and their course of development and termination in central 
coagulation necrosis, fatty changes, or caseation, also bears much general 
resemblance to the affections caused by the bacillus of tuberculosis. But 
there is a third point of parallelism. 

As long as softened tuberculous or syphilitic foci remain subcutaneous, 
and are not exposed to the influence of the air and its pus-generating germs, 
their course is bland and slow, and their tendency is to fatty degeneration, 
encapsulation, and final absorption. But, as soon as such a softening deposit 
comes under the influence of the pyogenic elements contained in the at- 
mospheric air, its slow and bland character is changed to a most destructive 
one. Thus syphilitic nodes of the internal organs, being protected from 
contact with the outer air, rarely, if ever, terminate in ulcerative destruc- 
tion : they generally tend to fatty involution, absorption, and cicatrization. 
Specific deposits of the outer skin, the mucous membranes — as, for example, 
of the nasal and oral bones — on the other hand, are all noted for their pro- 
nounced tendency to rapid ulceration or gangrenous destruction. 

As an illustration of a parallel behavior of tuberculous foci, cold ab- 
scesses and articular tuberculosis may be mentioned. Before perforation, 
their course is mild and slow ; but after the establishment of one or more 
sinuses they become the source of profuse secretion, and their course is 
characterized by rapid local destruction with general emaciation. 

The explanation of this peculiar difference in the behavior of syphilitic 
indurations or tumors, essentially identical in morbid character, is to be 
found in the fact that the poor nutrition and low vitality of the cellular 



322 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

elements composing a primary or secondary syphilitic node, exposed to 
pyogenic infection by contact with the outer air, offer very favorable con- 
ditions for the rapid development and destructive multiplication of germs, 
that are notoriously deleterious even to healthy tissues. Pus-generating 
cocci deposited on the excoriated surface of a syphilitic focus, as, for in- 
stance, a primary induration of the prepuce, or a gummy swelling of the 
nasal bones, will, by their multiplication, lead to massive invasion and rapid 
ulcerative destruction of the densely infiltrated and poorly nourished node. 

Syphilitic ulcers of every kind present a combination of syphilitic and of 
pyogenic infection. 

If we succeed by appropriate systemic treatment in preventing the ex- 
tension of the central softening of a syphilitic node to the surface, ulcerat- 
ive changes also will thus be prevented. For example, the timely admin- 
istration of large doses of iodide of potash may prevent necrosis of the nasal 
bones, which are the seat of a growing gummy swelling. Their dense infil- 
tration pertains to syphilis ; their necrosis, however, is caused by the invasion 
of pyogenic germs. But we possess another means for preventing ulcerative 
destruction of syphilitic deposits located in the outer skin. They are more 
exposed to pyogenic infection, but they are also more accessible to local 
remedies. • 

The aseptic protection of the surface of the primary induration offers an 
easy remedy for preventing the formation of the primary ulcer or chancre. 

True, that the prevention of the ulcerative destruction of a primary in- 
duration of the prepuce will not prevent the systemic development of 
syphilis ; but it will, nevertheless, constitute a valuable service rendered to 
the patient, who will be spared all the suffering, annoyance, and danger 
connected with the development of the primary ulcer. 

If a patient, exhibiting a recent primary induration of the penis, pre- 
sents himself for treatment before the appearance of the pustular excoria- 
tion, or before the epidermal film of the formed pustule is broken, and if 
the surgeon thoroughly cleanses and disinfects the affected parts, afterward 
carefully enveloping the penis in an aseptic dry dressing, ulceration of the 
indurated node — that is, the development of a primary ulcer — can be effectu- 
ally prevented. 

The node will lose its epidermidal covering, but the aseptic dressing will 
exclude pyogenic infection, and the course of development and involution 
of the syphilitic deposit will be as though it were subcutaneous. A small 
quantity of lymph will exude from the excoriated surface, will be imbibed 
by the aseptic dressing, and will exsiccate, thus forming a hermetic seal 
and protection to the diseased tissues. 

Fatty disintegration of the infiltrated tissues will be followed by the 
formation of new epidermis, and when, after three or four weeks, the dress- 
ings come off, a cicatrized though still somewhat indurated portion of skin 
will be exposed to view. 

Specific rash, and other manifestations of systemic infection, will appear 
in due course of time ; but the incalculable extension of the ulceration to 



ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 323 

adjoining non-infiltrated parts of the skin, and the formation of suppurat- 
ive buboes and other complications, will be obviated. The following case 
may serve as an illustration : 

Case.— H. B., aged twenty -five, presented himself January 2, 1887, with a hard, 
elevated node, the size of a nickel, occupying the dorsum penis, and another smaller 
induration near the frenulum. Suspicious cohabitation had been indulged in for some 
time until within a few days of the visit. Bilateral indolent inguinal lymphadenitis 
was noted, and the presence of specific infection was assumed. The patient was kept 
under daily observation, and was directed not to meddle with any blister that might 
appear on the indurated spots. January 8th. — A yellowish discoloration was observed 
occupying the apex of the larger node, and was looked upon as an indicatiou that a 
pustule was forming. The entire penis was carefully cleansed with green soap and 
warm water, and was disinfected with a 1: 1,000 solution of corrosive sublimate, good 
care being taken not to break the transparent layer of epidermis covering the dis- 
colored spot. A thick layer of iodoform powder was sprinkled over both indurated 
nodes, and a small patch of iodoformized gauze was placed over them — this being held 
down by a narrow, oblong compress of corrosive-sublimate gauze, snugly bandaged on 
with a muslin roller. The meatus was left exposed for micturition, and the patient 
was directed not to interfere with the dressings and to report daily. The first dress- 
ing remained undisturbed until January 17ih, when its external part, getting disar- 
ranged, was removed. The strip of iodoform gauze was found firmly attached to the 
underlying indurated nodes, and had the appearance of a hard, flat cake, that had been 
evidently soaked through by lymph or serum some time since its application. Evap- 
oration of its aqueous contents had converted it to the shape just described. It was 
left in situ, and a fresh outer dressing was applied. 

At the same date (January 17th) the girl with whom the patient had held com- 
merce, presented herself for examination at the author's request, and was found to be 
covered with a small, papulous, specific rash. The appearance of her throat, the uni- 
versal adenitis, and two freshly-cicatrized spots on the labia minora, left no doubt of 
her being subject to florid syphilis. She remained under prolonged specific treat- 
ment, and in July, 1887, still exhibited pharyngeal ulcerations. 

January 25th. — The dressings applied to the patient's penis became again disar- 
ranged, and had to be renewed. The immediate covering of the nodes, consisting of 
iodoform gauze, was still firmly adherent, and was left unchanged. 

February 12th. — A general maculous rash appeared on the patient's body, and sys- 
temic treatment by mercurial inunctions was commenced. 

February 20th. — The entire dressings came off — the strip of iodoform gauze in the 
shape of a perfectly dry scab, to the inner side of which was found attached a patch 
of shiny scales, consisting of effete epidermis. The noc'es, which were formerly promi- 
nent, had receded to the level of the surrounding skin, and the induration, which still 
could be felt, was marked by a coat of fresh-looking young epidermis. The patient 
received fifty inunctions of blue ointment, which freed him from all cutaneous symp- 
toms of the disease. In May, pharyngeal ulcerations appearing, the inunctions were 
resumed. Size and hardness of the initial sclerosis were visibly diminished by this time. 

It seems in the foregoing case that the ulcerative destruction of the pri- 
mary induration was forestalled by disinfection and subsequent aseptic 
management. Without them the imminent formation of an initial sore would 
have inevitably occurred. The treatment of the fully-developed chancre 
would certainly have been a much more disagreeable, painful, and filthy ex- 



324 RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 

perience than the simple manipulation of once cleansing and protecting the 
initial induration. The site of the morbid process thus protected against "ex- 
ternal irritation" — that is, pyogenic infection — ran, as it were, a subcuta- 
neous and bland course of slow involution, the aggregate of discharge during 
forty-three days not exceeding the small quantity required to permeate a 
strip of four layers of iodoformized gauze, covering an area of about two 
thirds of a square inch. 

2. Antiseptic Treatment of the Primary Syphilitic Ulcer.— The results 
obtained by the various time-honored and well-established forms of local 
treatment of the primary syphilitic ulcer all bear out the assumption that 
the specific alteration of the affected tissues only serves as a predisposing 
condition to the subsequent ulcerative destruction of the initial sclerosis. 
The ulceration is directly produced by the ingrafting of purulent infection 
on a soil, devitalized by the dense cellular infiltration, characteristic of 
initial sclerosis. The rapid destruction observed in chancre is always sig- 
nalized by the detachment of the epidermis raised in the shape of a pustule, 
under which we find a yellowish, brittle necrobiotic nucleus, which is the 
first to succumb to the onslaught of the pyogenic organisms, deposited on 
it by the manipulations of the patient or otherwise. 

The various forms of local treatment successfully employed for the cure 
of chancre are all antiseptic in character. 

Their aim is either the prompt removal of the infectious discharge by 
prolonged baths and frequent moist dressings, or disinsection by weak or 
concentrated caustics, or a combination of measures directed toward a rapid 
mechanical removal of the deleterious secretions, with chemical disinfection. 
As the most powerful and most effective arrester of the destructive course 
of phagedenic chancre, the actual cautery is to be mentioned — the sover- 
eign destroyer of all microbial parasites. 

a. Chemical Sterilization and Surface Drainage by Medicated 
Moist Dressings. — The energy to be applied to the local treatment of an 
ulcerating initial sclerosis should be proportionate to the virulence and de- 
structiveness of the morbid process. In most cases the resistance of the 
vital forces combating the morbid process will be sufficient to check the 
damage. This is attested by the numerous cases of neglected chancre that 
end ultimately in spontaneous cure. Hence, in most instances, a mild 
treatment by local antiseptic baths, combined with moist antiseptic dress- 
ings, will answer the purpose. 

Frequent removal of the soiled dressings forms the most essential part 
of this plan of therapy; The patient is directed to provide himself with a 
wide-mouthed, one-ounce vial, which is filled with suitably proportioned 
small, square pieces of lint or gauze, over which is poured a moderate quan- 
tity of a one-per-cent solution of carbolic acid, or a 1 : 5,000 solution of 
corrosive sublimate. The cork-stoppered vial can be easily carried by the 
patient, who is enjoined to dress the sore or sores at least once every hour, 
and oftener if the discharge be very profuse. In the morning and evening 
a prolonged local bath in the same solution is advisable. In many cases 



ASEPTICS AND ANTISEPTICS IN SYPHILITIC LESIONS. 325 

this plan will be sufficient to check the extension of the ulcer, and to bring- 
about cleansing of its bottom. 

Another mild form of antiseptic treatment consists of the application of 
iodoform powder to the ulcerating surface. The objectionable odor of the 
drug can be excellently masked by the admixture of equal parts of freshly 
roasted and ground coffee. As soon as the appearance of a cicatricial border 
is apparent, these modes of treatment should be abandoned in favor of the 
application of strips of mecurial plaster, which should be renewed in pro- 
portion to the amount of discharge. Cicatrization will be very much has- 
tened by this change. 

b. Chemical Sterilization by Strong Caustics. — Cases of greater 
virulence which do not yield within a fortnight or so to the mild plan of 
treatment by scrupulous cleansing and disinfection, or in which rapid ex- 
tension of the ulcer does not justify temporizing, require the application of 
escharotics. The author has found a fifty -per -cent solution of chloride of 
zinc the most convenient and most effective of all chemicals recommended 
for the cauterization of chancre. Its application is to be done as follows : 
The ulcer and its vicinity are subjected to a careful cleansing by a mop of 
cotton dipped in a 1 : 1,000 solution of corrosive sublimate. Crusts and 
scabs overlapping the edge of the sore must be gently removed. A small 
piece of clean blotting-paper is applied to the ulcer and its vicinity with 
gentle pressure to remove all moisture. A moderate quantity of the caustic 
solution is applied to the sore with a glass rod or match-stick, care being 
taken not to corrode unnecessarily the surrounding healthy skin. Previous 
thorough drying of the integument with blotting-paper will best prevent 
overflowing of the caustic. All the nooks and indentations of the margin 
of the ulcer must be carefully covered by the solution. As soon as the base 
of the sore assumes the color of parchment, which will occur in from three 
to five minutes, cauterization is completed, whereupon the surplus of caustic 
should be removed by the application of another piece of blotting-paper. 
The eschar is dusted with a little iodoform and coffee-powder, and is pro- 
tected from injury by a strip of moist lint or gauze. 

If the cauterization was sufficient, further extension of the ulcerative 
process will be arrested thereby. In from two to six days, according to the 
depth of the eschar, a narrow line of demarkation will appear, and, the 
eschar being detached, a healthy granulating surface will become visible. 
This should be dressed with strips of mercurial plaster until cicatrization is 
completed. 

Insufficient chemical cauterization will not check the ulcerative decay 
of the tissues. In proportion to the incompleteness of the application, par- 
tial or total extension of theulcer will be observed. In some cases only a 
tongue of renewed ulceration will be seen extending outward from the mar- 
gin of the eschar. In others, the ulceration will spread all around the 
cauterized patch, thus demonstrating the entire inadequacy of the applica- 
tion. The surgeon's error should be in favor of too much rather than too 

little of the caustic. 
43 



326 



RULES OF ASEPTIC AND ANTISEPTIC SURGERY. 



When the process is found to be extending more or less in spite of a pre- 
vious cauterization, the deficiency should be corrected without delay by a 
renewed application. 

c. Sterilization by the Actual Cautery. — Phagedenic forms of 
chancre, occurring on the penis, lips, or fingers, and characterized by dusky 
swelling and a rapidly-spreading, more or less gangrenous decay of the tissues, 
can be rarely arrested by anything short of the energetic application of the 
actual cautery. In some cases renewed searing will be required to check the 
trouble brought under control in one portion of the ulcer, but extending 
further in another direction from a limited part of the lesion. It is espe- 
cially important to search out all recesses overlapped by the undermined 
margin of integument, as they are the chief nidus of active infection. The 
thermo-cautery, or red-hot iron, should be well inserted in all of these re- 
cesses and sinuses, otherwise the result will be incomplete or entirely un- 
satisfactory. The wound should be packed with very narrow strips of iodo- 
form gauze while the patient is still under the influence of the indispensable 
anaesthetic, and care should be taken to line all nooks and crevices of the 
irregular wound with the gauze. The object of this is to prevent retention, 
and to secure prompt disinfection of the discharges which needs must be 
absorbed by the dressings. The penis is enveloped in an ample compress, 
moistened with warm carbolic lotion (one per cent), over which is placed a 
piece of rubber tissue to prevent evaporation. On the penis, daily change 
of dressings is to be done after a hip-bath, which will very much facilitate 
their painless removal. The febrile disturbance regularly noted with these 
most virulent forms of specific ulcer, and the 
general debility and anaemia, which is its 
main predisposing cause, require appropriate 
roborant and anti-febrile general treatment. 
As soon as cicatrization shall have com- 
menced, the affection is to be treated like 
a simple ulcer. 

The foregoing view of the relation of sup- 
puration to syphilitic lesions is based exclu- 
sively upon clinical data, and needs corrobo- 
ration at the hands of pathologists more ex 
pert in systematic and exact research than 
the author. One object of these re- 
marks was to arrange the clinical 
facts pertaining to syphilitic ulcera- 
tions under a general principle, from 
which the therapeutic measures usu- 
ally employed for their cure could be 

easily and logically deduced. FlG - 248.— Specific ulcer of index finger. 




INDEX. 



Abdominal drainage, 188. 

operations, 115. 

suture, 139. 

toilet, 138. 
Abscess, anal, 254. 

of bone, 205. 

cervical, 220. 

cold, 264. 

formation of, 179, 

glandular, 189. 

iliac, 247. 

of liver, 251. 

lumbar, 251. 

mammary, 223. 

mastoid, 221. 

metastatic, 181. 

pelvic, 246. 

perinephritis 251. 

perityphlitis 246. 

prevesical, 247, 249. 

psoas, 246. 

retroperitoneal, 246. 

self-limitation of, 180. 

tonsillar, 215. 

temporal, 221. 
Accidental wounds, 29. 
Acetic acid, 11. 

Active movements after joint exsection, 278. 
Actual cautery for syphilitic ulcers, 326. 
Adhesions, abdominal, 136. 
^Ether pneumonia, 148, 149, 152. 

nephritis, 118. 
Amputations, 59. 

dressings after, 72. 
Anal abscess, 254. 
Anal fistula, 256. 

excision of, 256. 

suture of, 257. 

tuberculous, 269. 
Anatomy of connective-tissue planes of neck, 
208. 

planes of pelvis, 246. 



Anaesthetics in herniotomy, dangerous depress- 
ing effect of, 125. 
Aneurism, 48. 

needle, 48. 
Anchylosis, beny, 84. 
Ankle-joint, exsection of, 293. 
Antisepsis, 27, 167. 

Antiseptics applied to primary syphilitic ul- 
cers, 324. 
Apnoea after tracheotomy, 101. 
Apparatus for the after-treatment of the ex- 

sected elbow-joint, 281. 
Aprons, 20. 

Arm, suppuration of, 230. 
Arteries, ligature of, 47. 
Artery forceps, 66. 
Arthrotomy, 75, 79. 

for elbow fracture, 80. 

for dislocation, 79. 

for habitual dislocation, 8. 
Artificial anaemia, 66. 

anus, 122. 
Aseptic cap, 89. 
Asepsis, 3. 

in peritoneal operations, 115. 
Aseptic wounds, 5. 

accidental wounds, 32. 
Aseptics of amputation, 59. 

of the orifices, 93. 

of rectum, 154. 
Axilla, evacuation of, 111. 
Axillary glands, 238. 

vein, 111. 

Bacteria of putrescence, 171. 

Bismuth, 11. 

Bladder, antiseptics of the, 159. 

treatment of, before ovariotomy, 138. 
Bloodclot, healing under the, 6. 
Bone abscess, 205. 

tuberculosis, 273. 
Boro-salicylic lotion, 10. 



328 



INDEX. 



Bose's methods of tracheotomy, 

Bottle-shaped wounds, 40. 

Bow-leg, 83. 

Bozeman's position, 154. 

Breast amputation, 109. 

Broad ligament, 142. 

Bursa, iliac, 250. 

olecranic, 238. 

prepatellary, 242. 

of quadriceps, 243. 

Cachexia strumipriva, 108. 
Cancer of tongue, 94. 
Caries, 273. 
Carbolic acid, 10. 
Carpal exsection, 284. 
Caseation, 264. 
Caseous infiltration, 264. 
Castration, 152. 
Cataplasms, 186. 
Catgut, 8. 

impure, 8. 

slipping of, 69 
Catheters, cleansing of, 159. 
Catheterism, 159. 
Cervical abscess, 220. 
Change of dressings, 20. 
Chisels, 198. 

Chloride-of-zinc solution, 825. 
Clap, 301. 

Cleanliness, surgical, 7. 
Cleansing process of feet, 61. 
Club-foot, 85. 
Cold abscess, 264, 273. 

applications, 187. 
Colotomy, lumbar, 147. 

inguinal, 148. 
Compressor urethroe, 301. 
Continuous suture, 45. 
Corrosive-sublimate lotion, 10. 
Coryza, scrofulous, 269. 
Cotton dressings, 15. 
"Cut-off" muscle, 160, 301. 
Cynanche, parotid, 219. 

sublingual, 217. 
Cyst of broad ligament, 142. 
Cystitis, 315. 
Cystotomy, perineal, 162. 

suprapubic, 163. 
Czerny's suture for hernia, 130. 

Deformities, 83. 
Diphtheria of fauces, 211. 
of intestine, 125. 



Dissection, technique of, 35. 
Dislocation, irreducible, 79. 

habitual, 79. 
Drainage, 59. 

abdominal, 138. 
Drainage-tubes, 9. 

T-shaped, for cystotomy, 164. 
Dressings, 11. 

for hand and forearm, 80. 
Dry dressings, 12. 

spores, 178. 
Dust, 5. 

Elastic ligatures, 9, 136. 

in anal fistula, 258. 
Elbow apparatus, 281. 

fracture, 80. 

joint, exsection of, 280. 
Embolism, septic, 181. 
Emergencies, 23. 
Emphysematous gangrene, 191. 
Empyema, 226. 
Endoscope, urethral, 308. 
Epididymitis, tuberculous, 269. 
Erysipelas, 170, 259. 

phlegmonous, 260. 
Esmarch's bandage, 67. 
Estlander's operation, 228. 
Excision of anal fistula, 256. 
Exsection of ankle-joint, 293. 

of elbow-joint, 280. 

of joints for tuberculosis, 275. 

of hip-joint, 285. 

of knee-joint, 287. 

of shoulder-joint, 278. 

of wrist, 284. 
External urethrotomy, 313. 
Extirpation of axillary glands, 239. 

of cervical glands, 51, 58. 

of inguinal glands, 55, 246. 

of tumors, 50. 

Face, carbuncle of, 210. 
Fauces, diphtheria of, 211. 
Faucial suppuration, 211. 
Feet, cleansing process of, 61. 
Femur, necrotomy of, 203. 
Fibrinous arthritis, 74. 
Finger-joints, exsection of, 238. 

suppuration, 237. 
Fistula in ano, 254. 

in ano, tubercular, 269. 
- thoracic, 228. 
Floating bodies, 77. 



INDEX. 



329 



Follicular tonsillitis, 212. 

Fresh cadavers, infectiousness of, 177. 

Funnel-shaped wounds, 40. 

Gastrostomy, 146. 
Gauze, 14. 

corrosive-sublimate, 15. 

iodoformized, 15. 
Giant cell, in tuberculosis, 264. 
Glandular tuberculosis, 269. 
Gleet, 307. 
Goitre, 107. 
Gonococcus, 299. 
Gonorrhoea, 299. 

acute, 301. 

anterioi-, 302. 

chronic, 307. 

deep-seated, 304. 

posterior, 304. 
Granular urethritis, 315. 
Granulations, infection of, 184. 
Gross dirt, 178. 
Gunshot wounds, 34. 

Habituation to septic influences, 183. 

Haemorrhoids, 154. 

Haemostatic needle, 41. 

Hahn's incision for exsection of knee-joint, 288. 

Hand, phlegmon of, 230. 

Hernia, congenital, 130. 

radical operation for, 128. 

strangulated, 119. 
Hernial sac, treatment of, 120. 
Herniotomy. 117. 

dressings after, 127. 
Hilton-Roser's method of incising abscesses, 

188. 
Hip-rest, Volkmann's, 127. 
Hip-joint exsection, 285. 
Hot applications, 187. 
Hydrocele, 149. 

tapping of, 150. 
Hygroma, proliferating, 271. 
Hysterectomy, 143. 

Iliac abscess, 247. 

bursa, 250. 
Immersion, continuous, 235. 
Incontinentia alvi, 258. 
Infection, portals of, 171. 
Infectiousness of tonsillitis, 214. 
Inflammation, 178. 
Ingrown toe-nail, 239. 
Inguinal glands, 245. 



Inguinal glands, suppuration of, 238, 245. 
Injections, urethral, 303. 
Instrument-pouch, 26. 
Intermuscular space, 209, 220. 
Internal urethrotomy, 311. 
Interrupted suture, 45. 
Intubation, 213. 
Iodoform, 11. 

dusting box, 15. 
Irrigation, 7. 

continuous, 235. 

of joints, 73. 

of the neck of the bladder, 304. 

of the urethra, 303. 
Irritation, caloric, 176. 

chemical, 176. 

mechanical, 175. 

Joints, after-treatment of, 277. 
Joint-exsection, 275. 
Joints, suppuration of, 73. 
tuberculosis of, 275. 

Kidney, surgical, 253. 

Klotz's endoscope, 308. 

Knee-joint exsection, technique of, 288. 

suppuration of, 242. 

tuberculosis of, 289. 
Knock-knee, S3. 

Lange's position for nephrotomy, 252. 

Laparotomy, exploratory, 133. 

Laryngeal operations, 97. 

Laryngofissure, 103. 

Larynx, extirpation of, 104. 

Laudable pus, 184. 

Lead-plate suture, Lister's, 45. 

Leg, ulcer of, 241. 

Leptothrix, 214. 

Ligatures, 8. 

Litliolapaxy, Bigelow's, 161. 

Little finger, suppuration of, 232. 

Liver abscess, 251. 

Lumbar abscess, 251. 

dressings, 254. 
Lupus, 268. 

Lymphadenitis, caseous, 269. 
Lymphangitis, 185. 

Maas's operation, 91. 
Mamma, amputation of, 109. 
Mammary abscess, 223. 
Mastitis, interstitial, 225. 
suppurative, 223. 



330 



INDEX. 



Mastoid abscess, 221. 

Measles and tuberculosis, 265. 

Meatotomy, 307. 

Mechanical irritation, 175. 

Mikulicz's operation, 293. 

Moist dressings, 13. 

Moss, IT. 

Mucous membranes, tuberculosis of, 269. 

Multiple puncturing, Volkmanu's, 186. 

Myxoedema, 108. 

Nails, arrangement of, 84. 

extraction of, after exsection of knee-joint, 
293. 

for knee-joint exsection, 289. 
Neck of the bladder, cauterization of, 306. 

irrigation of, 304. 
Neck, caseous lymphadenitis of, 2*70. 

connective-tissue planes of, 208. 
Necrosis of bone, 193. 

of gut, 123, 124. 
Necrotomy, 194. 
Needle-holder, 41. 
Nephrectomy, 145 
Neuber's implantation, 200. 

(Esophagus, retrograde catheterism of, 146. 

cancer of, 146. 
Olecranic bursa, 238. 
Open treatment, 66. 
Operating bag, 25. 
Oral cavity, 93. 
Orchitis, tuberculous, 269. 
Osteomyelitis, acute infectious, 191. 
Otis's urethrometer, 307. 
Ovarian tumors, 140. 

Palmar bursa, 232. 

suppuration, 231. 
Passive movements, 75. 

after joint exsection, 277. 
Pasteboard splints, 281. 
Patella, suturing of fractured, 77. 
Pelvic abscesses, 246. 
Pelvis, connective-tissue planes of, 246. 
Perineoplasty, 91. 
Perinephritic abscess, 251. 
Peritoneal tuberculosis, 118. 
Peritonaeum, protection of, 138. 
Peritonitis after abdominal section, 117. 
Perityphlic abscess, 246. 
Perivascular interspace, 209, 220. 
Pes valgus, 85. 
Phelps's operation, 85. 



Phlegmon, cause of, 169. 
Phlegmon, cutaneous, 185. 

retro-pharyngeal, 215. 

subcutaneous, 185. 

subfascial, 189. 

treatment of, 184. 
Phlegmonous erysipelas, 190. 
Plastic operations, 88. 
Pleurisy, purulent, 226. 
Pneumonia, from aether, 148, 149, 152. 
Predisposition to tuberculosis, 265. 
Prepatellary bursa, 242. 
Prevesical abscess, 247, 249. 
Previsceral interspace, 208. 
Primary induration, syphilitic, 321. 

ulcer, syphilitic, 322. 
Probing of wounds, 193. 
Proctoplasty, 258. 
Prostatic syringe, Ultzmann's, 306. 
Pseudo-erysipelas, 260. 
Psoas abscess, 246. 
Ptomaines, 4. 

Puncture of abdominal tumors, 137. 
Purse-string suture, 126. 
Putrescence, bacilli of, 171. 
Pyaemia, 182. 

Quadriceps, bursa of, 243. 
Quilled suture, 139. 
Quinsy sore throat, 215. 

Radical operation for hernia, 128. 

for hydrocele, 150. 

for varicocele, 151. 
Rectal tampon-tube, 155. 
Rectum, aseptics of, 154. 
Retractors, 39. 

Retrograde catheterism of oesophagus, 146. 
Retro-peritoneal abscess, 246. 
Retro-pharyngeal abscess, 215. 
Retro-visceral interspace, 208. 
Revision for tuberculosis, 274. 
Rose's position of head, 213. 
Rubber sheets, arrangement of, 75, 80. 
Rubber tissue, 12, 13. 

Sawdust, 16. 

Saws, disinfection of, 63. 

Schede's dressing, 12, 203. 

Schroeder's suture of uterine stump, 144. 

Scrofula, 269. 

Sepsin, 4. 

Sepsis, 3. 

Septic fever, 179. 



INDEX. 



331 



Shock after laparotomy, 145. 
Shoulder-joint, exsection of, 2*78. 
Sigmund's urethral syringe, 303. 
Silk, 9. 

Silk-worm gut, 9. 
Soiled accidental wounds, 31. 
Solutions for disinfection, 10. 
Spanish windlass, 30. 
Splints of pasteboard, 280. 
Sponges, 8. 

in laparotomy, 134. 
Spray-apparatus, 134. 
Staphylococcus, 169. 
Starcke's irrigation-tube, 236. 
Sterilization, chemical, 7. 
Strangulating hernial band, 120. 
Strangulated hernia, 119. 
Streptococcus, 169. 
Stricture, urethral, 301. 

incipient, 30*7. 

permanent or cicatricial, 309. 
Styptic solutions, abuse of, 230. 
Submaxillary capsule, 208, 218. 
Suction lead, 45. 
Suppuration, cause of, 169. 

spread of, 179. 

superficial, 185. 
Suppurations on the face, 209. 

of the fauces, 211. 
Surgical kidney, 253. 
Suture, abdominal, 139. 

of anal fistula, 257. 
Sutures, 8, 43. 

Suturing fractured patella, 77. 
Syphilitic external lesions, 321. 
Syphilitic ulcer, caustic treatment of, 325. 

primary, 324. 

moist treatment of, 325. 

treatment by the actual cautery of, 326. 

T-bandage, 157. 

T-splint, Volkmann's, 74. 

Tampon cannula, Gerster's, 94. 

Tampon-tube, rectal, 157. 

Temporal abscess, 221. 

Tendinous sheaths, tuberculosis of, 271. 

Testis, necrosis of, 152. 

removal of, 152. 
Thiersch's solution, 10. 

spindle-apparatus, 41. 
Thomas's operation for mammary tumors, 

110. 
Thoracic fistula, 228. 
Thrombosis of pulmonary artery, 114, 227. 



Thrombosis, septic, 181. 

venous, 114. 
Through-drainage, 46. 
Thumb, suppuration of, 232. 
Toilet, abdominal, 138. 
Tongue, 94. 

Tonsils, cauterization of, 213. 
Tonsillar abscess, 215. 
Tonsillitis, 213. 
Tracheotomy, preliminary, 94, 97. 

superior, 99. 

inferior, 100. 

for goitre, 109. 
Trendelenburg's T-shaped drainage-tube, 164. 
Trocars, disinfection of, 73. 
Tuberculosis, 263. 

of ankle-joint, 293. 

of bone, 273. 

cutaneous, 268. 

dissemination of, 265. 

general treatment of, 269. 

of joints, 275. 

of knee-joint, 289. 

local treatment of, 268. 

of lymphatic glands, 269. 

of mucous membranes, 269. 

of peritonaeum, 118. 

prevention of, 269. 

and pyogenic infection, combination of, 
267. 

of tendinous sheaths, 271. 

of testicle, 269. 
Tuberculous infection, direct, 266. 

through the lungs, 265. 
Tumors, extirpation of, 50. 

Ulcer of leg, 241. 

Ultzmann's method of irrigating the neck of 
the bladder, 304. 

prostatic syringe, 306. 

test, 302. 
Uraemia from a3ther, 118. 
Urethral endoscope, 308. 

injections, 303. 

irrigation, 303. 

stricture, 301. 

syringe, Sigmund's, 303. 

tuberculosis, 269. 

vegetations, 315. 
Urethritis, chronic, 315. 

granular, 315. 
Urethrometer, Otis's, 307. 
Urethroplasty, 90. 
Urethrotomy, external, 313. 



332 



INDEX. 



Urethrotomy, internal, 311. 
Uterine stump, 144. 

Varicocele, 151. 
Vein, axillary, 111. 
Veins, exsection of, 57. 

injury of femoral, 56. 

lateral closure of, 55. 

treatment of, 42. 



Venereal vegetations, urethral, 315. 
Vermiform appendix, necrosis of, 124. 
Vertical suspension of limbs, 235. 
Vesical tuberculosis, 269. 
Volkmann's hip-rest, 127. 

multiple puncturing, 186. 

suspension splint, 235. 

White swelling, 275. 



THE END. 



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"The large number of readers who are 
already familiar with this work will be glad 
to learn that the present edition has been 
carefully revised by the author, considerably 
enlarged, and is intended to include all that 
has in the most recent period been added to 
practical medicine, especially in its clinical 
horizon. The author felicitates himself on 
the large sales obtained for the previous edi- 
tions, and there is no reason why the pres- 
ent one should not continue to gain in the 
: opinion of many. What doubtless lends 
I the volume one of its special attractions to 
\ these is the authoritative expressions which 
are frequent in its pages on subjects where 
the reader might be left in uncertainty else- 
where. This remark applies both to pa- 
thology and treatment. The fullness with 
which therapeutics are taught stands in 
noteworthy contrast to the majority of treat- 
ises on practice. This, too, is undoubtedly 
a feature which will be agreeable to numer- 
\ <'' j .,""".* ous purchasers. Some seeming excess of 

" conciseness in certain portions is explained 

'^'' by the fact that this is but one volume of a 

series proposed by the author, which will 
cover the whole domain of special pathology and therapeutics." — Medical and Surgical Reporter. 

' ' The deserved popularity of this work is attested 
by the fact that the first edition was issued in 1880, 
that a second was demanded in three months, and 



'■': 



' ' That six editions of such a work should be 
called for in six years is, perhaps, the most flattering 
testimonial that a book can receive, and must out- 
weigh every other comment, favorable or unfavor- 
able. In the preface to this edition is an announce- 
ment which will be welcomed by all of Dr. Bartho- 
low's numerous admirers, namely, that he has now 
in preparation another work on the ' Principles of 
Medicine ' which, together with the one under review, 
and his 'Materia Medica and Therapeutics,' shall 
constitute a trio of volumes, each containing matter 
complementary to the others. Certainly three such 
volumes must constitute a monument which will ren- 
der the writer's fame almost undying." — Medical 
Press of Western New York. 

" Professor Bartholow announces in the preface 
of this edition his intention of preparing: a work in 
three volumes which shall cover the whole domain 
of special pathology and therapeutics. The volume 
on ' Materia Medica ' appeared some time ago, but 
the third volume, which will treat of the ' Principles 
of Medicine,' is now in course of careful preparation, 
and will, when published, complete a most valuable 
set. The present edition of Professor Bartholow's 
1 Practice ' is considerably larger than the last, several 
new subjects having been introduced, together with 
numerous new illustrations. It is deservedly popu- 
lar with practitioners and students, and likely ere 
long to become one of the standard works on prac- 
tice, if it has not already attained this position." — 
Pacific Medical and Surgical Journal and Western 
Lancet. 



that the others have followed them in rapid suc- 
cession and been met by appreciative students al- 
ways. The author says in his preface to this edition 
that he has sought to make it worthy of the appro- 
bation of his readers by increasing the practical re- 
sources of his work, devoting his attention chiefly to 
the clinical aspects of medicine, without overlooking 
the advances made in the scientific branch. This 
book, like the previous editions of the work, is the 
product of a master and an honored authority, and 
in its new form, with such of the latest ideas as the 
author can conscientiously indorse or present for 
consideration, continues to hold its place among the 
standard text-books on all matters included in it." — 
North Carolina Medical Journal. 

" This valuable work appears in its sixth edition 
considerably enlarged, and improved materially in 
many respects. The arrangement of the subjects 
apnears to be pretty much the same as in former 
editions, and the description of diseases is also little 
modified. Some new chapters have been added, 
however, and new subjects introduced, making the 
volume completely cover the entire domain of prac- 
tice, without anything superfluous. Considering 
the immense scope of subjects, the directness of 
statement, and the plain, terse manner of dealing 
with the phenomena of disease, this practical work 
has no counterpart."— Kansas City Medical Rec- 
ord. 



D. APPLETON &- CO.'S MEDICAL WORKS. c 

ON THE ANTAGONISM BETWEEN MEDICINES 

AND BETWEEN REMEDIES AND DISEASES. Being the Cart- 
wright Lectures for the Year 1880. By Roberts Bartholow, M. A., 
M. D., LL. D., Professor of Materia Medica and General Therapeutics in 
the Jefferson Medical College of Philadelphia, etc., etc. 
1 vol., 8vo. Cloth.. $1.25. 

' ' We are glad to possess, in a form convenient no doubt that this, his latest contribution to medi- 

for reference, this most recent summary of the physi- cal science, will add materially to his previously high 

ological action of important remedies, with the de- reputation. Much profit, no little pleasure, and 

ductions of a careful and accomplished observer, re- material assistance in the solution of many thera- 

garding the applications of this knowledge to dis- peutical problems are to be obtained from a perusal 

eased states." — College and Clinical Record. of these lectures. The author has done wisely and 

"There are few writers who have taken the conferred a boon by permitting their publication in 

trouble to compile the lucubrations of the multitude ™ e present book-form, and we are satisfied it will 

of scribblers who find a specific in every drug they be extensively asked for, and just as extensively read 

happen to prescribe for a self-limited, non-malig- ^ d appreciated. — Canada Medical and Surgical 

nant disease , and fewer who can detect the trashy Journal. 

chaff and garner only the ripe, plump grains. This " It will be observed that the scope of the work 

Bartholow has done, and no one is more ripe, nor is extensive, and, in justice to the author, not only 

better qualified for this herculean task; and, the is the extent of this indicated, but the character of 

best of all is, condense it all in his antagonisms. it is also furnished. No one can read the synopsis 

No one can peruse its pregnant pages without no- given without being impressed with the importance 

ticing the painstaking research and large collection and diversity of the subjects considered. Indeed, 

of authorities from which he has drawn his conclu- most of the important forces in therapeutics and 

sions. The practitioner who purchases these antag- materia medica are herein stated and analyzed. " — 

onisms will find himself better quaLaed to cope with American Medical Bi- Weekly. 

the multifarious maladies after its careful perusal." » p ro bablv most of our' readers will consider 

—Indiana Medical Reporter. that we have awar ded this treatise high praise when 

" The criticisms made upon these lectures have we say that it seems to us the most carefully writ- 

invariably been most favorable, the topic itself is ten, best thought-out, and least dogmatic work 

one of the most interesting in the entire range of which we have yet read from the pen of its author, 

medicine, and it is treated of by the accomplished It is indeed a very praiseworthy book ; not an origi- 

author in a most scholarly manner. Dr. Bartholow nal research, indeed, but, as a resume of the world's 

worthily ranks as one of the best writers, while at work upon the subject, the best that has hitherto 

the same time one of the most diligent workers, in been published in any language." — Philadelphia 

the medical field in all America, and there can be Medical Times. 

WINTER AND SPRING ON THE SHORES OF THE 

MEDITERRANEAN; or, the Genoese Rivieras, Italy, Spain, Corfu, 

Greece, the Archipelago, Constantinople, Corsica, Sicily, Sardinia, Malta, 

Algeria, Tunis, Smyrna, Asia Minor, with Biarritz and Arcachon, as Winter 

Climates. By James Henry Bennet, M. D., Member of the Royal College 

of Physicians, London, etc., etc. 

Fifth edition. With numerous Illustrations and Maps. I vol., i2mo, 655 pp. Cloth, $3.50. 

This work embodies the experience of fifteen winters and springs passed by Dr. Bennet on the 
shores of the Mediterranean, and contains much valuable information for physicians in relation to 
the health-restoring climate of the regions described. 

" We commend this book to our readers as a vol- once entertaining and instructive." — Xew York 
ume presenting two capital qualifications— it is at Medical Journal. 

ON THE TREATMENT OF PULMONARY CON- 
SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with 
Modern Doctrines. By James Henry Bennet, M. D., Member of the 
Royal College of Physicians, London; Doctor of Medicine of the Uni- 
versity of Paris, etc., etc. 

1 vol., thin 8vo, 190 pp. Cloth, $1.50. 

An interesting and instructive work, written in the strong, clear, and lucid manner which ap- 
pears in all the contributions of Dr. Bennet to medical or general literature. 

"We cordially commend this book to the at- temperate climates, pulmonary consumption." — De- 
tention of all, for its practical, common-sense views troit Review of Medicine. 
of the nature and treatment of the scouige of all 



6 



D. APPLE TON &* CO.'S MEDICAL WORKS. 



GENERAL SURGICAL PATHOLOGY AND THERA- 
PEUTICS, in Fifty-one Lectures. A Text-Book for Students and Phy- 
sicians. By Dr. Theodor Billroth, Professor of Surgery in Vienna. 
With Additions by Dr. Alexander von Winiwarter, Professor of Surgery in 
Liittich. Translated from the fourth German edition with the special per- 
mission of the author, and revised from the tenth edition, by Charles E. 
Hackley, A. M., M. D., Physician to the New York and Trinity Hospitals; 
Member of the New York County Medical Society, etc. 
I vol., 8vo, 835 pp. Cloth, $5.00; sheep, $6.00. 




Giant-celled Sarcoma with Cysts and Ossifying Foci from the Lower Jaw. — Magnified 350 diameters. 

" Since this translation was revised from the sixth German edition in 1874, two other editions 
have been published. The present revision is made to correspond to the eighth German edition. 

" Lister's method of antiseptic treatment is referred to in various places, and other new points 
that have come up within a few years are discussed. 

"A chapter has been written on amputation and resection. In all, there are seventy-four 
additional pages, with a number of woodcuts." — Extract from Translator 's Preface to the Revised 
Edition. 

" The want of a book in the English language, 
presenting in a concise form the views of the Ger- 
man pathologists, has long been felt, and we ven- 



ture to say no book could more perfectly supply 
that want than the present volume." — The Lan- 
cet. 



THE PHYSIOLOGICAL AND THERAPEUTICAL 

ACTION OF ERGOT. Being the Joseph Mather Smith Prize Essay for 

1881. By Etienne Evetzky,.M. D. 

1 vol., 8vo. Limp cloth, $1.00. 

"In undertaking the present work my object was to present in a condensed manner all the 
therapeutic possibilities of ergot. In a task of this nature, original research is out of the ques- 
tion. No man's evidence is sufficient to establish the merits of a drug considered in the manner 
indicated, and no one man's opportunities are sufficient to grasp the entire subject. Consequently 
it remained to gather from the volumes of past and current periodical literature the testimony of 
the multitude of physicians that had been led to use ergot in different morbid conditions. I have 
recorded everything that has come to my notice, I have grouped and classified the immense mate- 
rial in our possession. In all cases in which the action of ergot could be explained, I have at- 
tempted to do so, although this task is frequently difficult, if not impossible. . . . The reader will 
see that ergot has been used in a large number of diseases ; some of these uses have little or no 
practical value, yet it is very important to know them, as they serve to illustrate the therapeutic 
properties of the drug. They have been brought to the notice of the reader without any com- 
ments, but those that are essential and of the greatest practical importance have been dealt with 
more fully. Among the latter may be mentioned the use of ergot in inflammation, aneurism, car- 
diac diseases, the post-parturient state, uterine fibroid tumors, rheumatism, etc. ; ' — From Preface. 



D. APPLETON &* CO.'S MEDICAL WORKS. y 

OBSTETRIC CLINIC. A Practical Contribution to the Study 

of Obstetrics, and the Diseases of Women and Children. By George T. 

Elliot, M. D., late Professor of Obstetrics and Diseases of Women and 

Children in the Bellevue Hospital Medical College ; Physician to Bellevue 

Hospital and to the New York Lying-in Asylum, etc. 

I vol., 8vo, 458 pp. Cloth, $4-50. 

This work is, in a measure, a resume 'of separate papers previously prepared by the late Dr. 
Elliot; and contains, besides, a record of nearly two hundred important and difficult cases in mid- 
wifery, selected from his own practice. The cases thus collected represent faithfully the diffi- 
culties, anxieties, and disappointments inseparable from the practice of obstetrics, as well as some 
of the successes for which the profession are entitled to hope in these arduous and responsible 
tasks. It has met with a hearty reception, and has received the highest encomiums both in this 
country and in Europe. 

THE SOURCE OF MUSCULAR POWER. Arguments 

and Conclusions drawn from Observations upon the Human Subject under 
conditions of Rest and of Muscular Exercise. By Austin Flint, Jr., M. D., 
Professor of Physiology in the Bellevue Hospital Medical College, New 
York, etc., etc. 

I vol., 8vo, 103 pp. Cloth, $1.00. 

"There are few questions relating to Philosophy of greater interest and importance than the 
one which is the subject of this essay. I have attempted to present an accurate statement of my 
own observations and what seem to me to be the logical conclusions to be drawn from them, as 
well as from experiments made by others upon the human subject under conditions of rest and of 
muscular exercise." — From the Preface. 

ON THE PHYSIOLOGICAL EFFECTS OF SEVERE 

AND PROTRACTED MUSCULAR EXERCISE. With special ref- 
erence to its Influence upon the Excretion of Nitrogen. By Austin Flint, 
Jr., M. D., Professor of Physiology in the Bellevue Hospital Medical Col- 
lege, New York, etc., etc. 

1 vol., 8vo, 91 pp. Cloth, $1.00. 

This monograph on the relations of Urea to Exercise is the result of a thorough anil careful 
investigation made in the case of Mr. Edward Fayson Weston, the celebrated pedestrian. The 
chemical analyses were made under the direction of R. O. Doremus, M. D., Professor o f Chem- 
istry and Toxicology in the Bellevue Iio-.piLil Medical College, by Mr. Oscar Loew, his assistant. 
The observations were made with the co-operation of J. C. Dalton, M. D., Professor of Physiol- 
ogy in the College of Physicians and Surgeons; Alexander B. Mott, M. D., Professor of Surgical 
Anatomy; \V. H. Van Buren, M. D., Professor of Principles of Surgery; Austin Flint, M. D., 
Professor of the Principles and Practice of Medicine; W. A. Hammond, M. D., Professor of the 
Diseases of the Mind and Nervous System — ^all of the Bellevue Hospital Medical College. 

MANUAL OF CHEMICAL EXAMINATION OF THE 

URINE IN DISEASE. With Brief Directions for the Examination of 

the most Common Varieties of Urinary Calculi. By Austin Flint, Jr., 

M. D., Professor of Physiology and Microscopy in the Bellevue Hospital 

Medical College ; Fellow of the New Vork Academy of Medicine, etc. 

Fifth edition, revised and corrected. I vol., i2mo, 77 pp. Cloth, $1.00. 

The chief aim of this little work is to enable the busv practitioner to make for himself, rapidly 
and easily, all ordinary examinations of Urine; to give him the benefit of the author's experience 
in eliminating little difficulties in the manipulations, and in reducing processes of analysis to the 
utmost simplicity that is consistent with accuracy. 

" "We do not know of any work in English so reputation of the author is a sufficient guarantee of 
complete and handy as the Manual now offered to the accuracy of all the directions given." — Journal 
the Profession by Dr. Flint, and the high scientific of Applied' Chemistry. 



8 



D. APPLETON &•> CO.'S MEDICAL WORKS. 



TEXT-BOOK OF HUMAN PHYSIOLOGY, for the Use 

of Students and Practitioners of Medicine. By Austin Flint, Jr., M. D., 
Professor of Physiology and Physiological Anatomy in the Bellevue Hospital 
Medical College, New York ; Fellow of the New York Academy of Medi- 
cine, etc. 
Third edition. Revised and corrected. In one large 8vo volume of 978 pp., elegantly printed on 

fine paper, and profusely illustrated with three Lithographic Plates and 315 Engravings on 

Wood, Cloth, $6.00; sheep, $7.00. 




Stomach, Pancreas, Large Intestine, etc. 

" The author of this work takes rank among the 
very foremost physiologists of the day, and the care 
which he has bestowed in bringing this third edition 
of his text-book up to the present position of his 
science is exhibited in every chapter." — Medical and 
Surgical Reporter (Philadelphia). 

"In the amount, of matter that it contains, in 
the aptness and beauty of its illustrations, in the 
variety of experiments described, in the complete- 
ness with which it discusses the whole field of human 
physiology, this work surpasses any text-book in 
the English language." — Detroit Lancet. 

" The student and the practitioner, whose sound 
practice must be based on an intelligent appreciation 
of the principles of physiology, will herein find all sub- 
jects in which they are interested fully discussed and 
thoroughly elaborated." — College and Clin. Record. 

" We have not the slightest intention of criticis- 
ing the work before us. The medical profession 
and colleges have taken that prerogative out of the 



Longitudinal Section of the Human Larynx, 
^showing the Vocal Cords. 



hands of the journalists by adopting it as one of 
their standard text-books. The work has very few 
equals and no superior in our language, and every- 
body knows it." — Hahnemannian Monthly. 

" We need only say that in this third edition the 
work has been carefully and thoroughly revised. It 
is one of our standard text-books, and no physician's 
library should be without it. We treasure it highly, 
shall give it a choice, snug, and prominent position 
on our shelf, and deem ourselves fortunate to pos- 
sess this elegant, comprehensive, and authoritative 
work. " — American Specialist. 

' ' Professor Flint is one of the most practical 
teachers of physiology in this country, and his book 
is eminently like the man. It is very full and com- 
plete, containing practically all the established facts 
relating to the different subjects. This edition con- 
tains a number of important additions and changes, 
besides numerous corrections of slight typographical 
and other errors."— Ohio Medical Recorder. 



D. APPLETON &* CO.'S MEDICAL WORKS. 



9 



THE PHYSIOLOGY OF MAN. Designed to represent the 

Existing State of Physiological Science as applied to the Functions of the 
Human Body. By Austin Flint, Jr., M. D., Professor of Physiology and 
Physiological Anatomy in the Bellevue Hospital Medical College, New 
York; Fellow of the New York Academy of Medicine, etc., etc. 
New and thoroughly revised edition. In 5 vols., 8vo. Per volume, cloth, $4.50; sheep, $5.50. 

Volume I. The Blood ; Circulation ; Respiration. 

Volume II. Alimentation ; Digestion ; Absorption ; Lymph and Chyle. 

Volume III. Secretion; Excretion; Ductless Glands; Nutrition; Animal 

Heat; Movements; Voice and Speech. 
Volume IV. The Nervous System. 
Vo'lume V. Special Senses ; Generation. 



"As a book of general information it will be 
found useful to the practitioner, and, as a book of 
reference, invaluable in the hands of the anatomist 
and physiologist." — Dublin Quarterly Journal of 
Medical Science. 

" Dr. Flint's reputation is sufficient to give a 
character to the book among the profession, where 
it will chiefly circulate, and many of the facts given 



have been verified by the author in his laboratory 
and in public demonstration." — Chicago Courier. 

" The author bestows judicious care and labor. 
Facts are selected with discrimination, theories crit- 
ically examined, and conclusions enunciated with 
commendable clearness and precision.' — American 
Journal of the Medical Sciences. 



SYPHILIS AND MARRIAGE. Lectures delivered at the 

St. Louis Hospital, Paris. By Alfred Fournier, Professeur a la Faculte 
de Medecine de Paris ; Medecin de l'Hdpital Saint-Louis. Translated by 
P. Albert Morrow, M. D., Physician to the Skin and Venereal Department 
New York Dispensary, etc., etc. 

1 vol., 8vo. Cloth, $2.00; sheep, $3.00. 



" The book supplies a want long recognized in 
medical literature, and is based upon a very ex- 
tended experience in the special hospitals for syphilis 
of Paris, which have furnished the author with a rich 
and rare store of clinical cases, utilized by him with 
great discrimination, originality, and clinical judg- 
ment. It exhibits a profound knowledge of its sub- 
ject under all relations, united with marked skill and 
tact in treating the delicate social questions neces- 
sarily involved in such a line of investigation. The 
entire volume is full of information, mnemonically 
condensed into axiomatic 'points.' It is a book to 
buy, to keep, to read, to profit by, and to lend to 
others." — Boston Medical and Surgical Journal. 

" This work of the able and distinguished French 
syphilographer, Professor Fournier, is without doubt 
one of the most remarkable and important produc- 
tions of the day. Possessing profound knowledge 
of syphilis in all its protean forms, an unexcelled 
experience, a dramatic force of expression, untinged, 
however, by even a suspicion of exaggeration, and 
a rare tact in dealing with the most delicate prob- 
lems, he has given to the world a series of lectures 
which, by their fascination of style, compels atten- 
tion, and by their profundity of wisdom carries con- 
viction." — St. Louis Courier of Medicine and Col- 
lateral Sciences. 

"Written with a perfect fairness, with a supe- 
rior ability, and in a style which, without aiming at 
effect, engagss, interests, persuades, this work is one 
of those which ought to be immediately placed in 
the hands of every physician who desires not only 
to cure his patients, but to understand and fulfill his 
duty as an honest man." — Lyon Medicate. 

' No physician, who pretends to keep himself 



informed upon the grave social questions to which 
this disease imparts an absorbing interest, can afford 
to leave this valuable work unread." — St. Louis 
Clinical Record. 

" The author handles this grave social problem 
without stint. A general perusal of this work would 
be of untold benefit to society." — Louisville Medical 
News. 

1 ' The subject is treated by Professor Fournier in 
a manner that is above criticism. Exhaustive clini- 
cal knowledge, discriminating judgment, and thor- 
ough honesty of opinion are united in the author, 
and he presents his subject in a crisp and almost 
dramatic style, so that it is a positive pleasure to 
read the book, apart from the absolute importance 
of the question of which it treats." — New York 
Medical Record. 

" Every page is full of the most practical and 
plain advice, couched in vigorous, emphatic lan- 
guage." — Detroit Lancet. 

1 ' The subject here presented is one of the most 
important that can engage the attention of the pro- 
fession. The volume should be generally read, as 
the subject-matter is of great importance to society." 
— Maryland Medical Journal. 

"We can give only a very incomplete idea of 
this work of M. Fournier, whicn, by its precision, 
its clearness, by the forcible manner in which the 
facts are grouped and presented, defies all analysis. 
' Syphilis and Marriage ' ought to be read by all 
physicians, who will find in it, first of all, science, 
but who will also find in it, during the hours they 
devote to its perusal, a charming literary pleasure." 
— Annates de Dermatologie et de Syphiligraphie. 



IO 



D. APPLETON &* CO.'S MEDICAL WORKS. 



CYCLOPEDIA OF PRACTICAL RECEIPTS, and Col- 

lateral Information in the Arts, Manufactures, Professions, and Trades, 
including Medicine, Pharmacy, and Domestic Economy. Designed as a 
Comprehensive Supplement to the Pharmacopoeia, and General Book of 
Reference for the Manufacturer, Tradesman, Amateur, and Heads of Fam- 
ilies. Sixth edition, revised and partly rewritten by Richard V. Tuson, 
Professor of Chemistry and Toxicology in the Royal Veterinary College. 
Corrplete in 2 vols., 1,796 pp. With Illustrations. Cloth, $9.00. 

Cooley's "Cyclopaedia of Practical Receipts " has for many years enjoyed an extended reputa- 
tion for its accuracy and comprehensiveness. The sixth edition, now just completed, is larger 
than the last by some six hundred pages. Much greater space than hitherto is devoted to Hygiene 
(including sanitation, the composition and adulteration of foods), as well as to the Arts, Phar- 
macy, Manufacturing Chemistry, and other subjects of importance lo those for whom the work is 
intended. The articles on what is commonly termed "Household Medicine" have been ampli- 
fied and numerically increased. 

The design of this work is briefly but not completely expressed in its title-page. Independ- 
ently of a reliable and comprehensive collection of formulae and processes in nearly all the indus- 
trial and useful arts, it contains a description of the leading properties and applications of the 
substances referred to, together with ample directions, hints, data, and allied information, cal- 
culated to facilitate the development of the practical value of the book in the shop, the laboratory, 
the factory, and the household. Notices of the substances embraced in the Materia Medica, in 
addition to the whole of their preparations, and numerous other animal and vegetable substances 
employed in medicine, as well as most of those used for food, clothing, and fuel, with their eco- 
nomic applications, have been included in the work. The synonyms and references are other addi- 
tions which will prove invaluable to the reader. Lastly, there have been appended to all the 
principal articles referred to brief but clear directions for determining their purity and commercial 
value, and for detecting their presence and proportions in compounds. The indiscriminate adop- 
tion of matter, without examination, has been uniformly avoided, and in no instance has any form- 
ula or process been admitted into this work, unless it rested on some well-known fact of science, 
had been sanctioned by usage, or come recommended by some respectable authority. 



THE COMPARATIVE ANATOMY OF THE DOMES- 
TICATED ANIMALS. By A. Chauveau, Professor at the Lyons Vet- 
erinary School. Second edition, revised and enlarged, with the co-operation 
of S. Arloing, late Principal of Anatomy at the Lyons Veterinary School: 
Professor at the Toulouse Veterinary School. Translated and edited by 
George Fleming, F. R. G. S., M. A. I., Veterinary Surgeon, Royal Engineers, 
vol., 8vo, 957 pp. With 450 Illustrations. Cloth, $6.00, 

Specimen of Illustration. 




"Taking it altogether, the book is a very wel- 
come addition to English literature, and great credit 
is due to Mr. Fleming for the excellence of the trans- 
lation, and the many additional notes he has ap- 
pended to Chauveau's treatise." — Lancet {London). 

" The descriptions of the text are illustrated and 



assisted by no less than 450 excellent woodcuts. In 
a work which ranges over so vast a field of anatomi- 
cal detail and description, it is difficult to select any 
one portion for review, but our examination of it 
enables us to speak in high terms of its general ex- 
cellence. . . ." — Medical Times a?zd Gazette {Lon- 
don). 



D. APPLETON &* CO.'S MEDICAL WORKS. 



II 



THE HISTOLOGY AND HISTO-CHEMISTRY OF 

MAN. A Practical Treatise on the Elements of Composition and Struc- 
ture of the Human Body. By Heinrich Frey, Professor of Medicine in 
Zurich. Translated from the fourth German edition, by Arthur E. J. Bar- 
ker, Surgeon to the City of Dublin Hospital ; Demonstrator of Anatomy, 
Royal College of Surgeons, Ireland ; and revised by the Author. With 680 
Engravings. 

1 vol., 8vo, 683 pp. Cloth, $5; sheep, $6. 

CONTENTS.— The Elements 
of Composition and of Structure 
of the Body : Elements of Com- 
position — Albuminous or Protein 
Compounds, Hsemoglobulin, His- 
togenic Derivatives of the Albu- 
minous Substances or Albumi- 
noids, the Eatty Acids and Fats, 
the Carbo-hydrates, Non-Nitro- 
genous Acids, Nitrogenous Acids, 
Amides, Amido-Acids, and Or- 
ganic Bases, Animal Coloring 
xMatters, Cyanogen Compounds, 
Mineral Constituents ; Elements 
of Structure — the Cell, the Origin 
of the Remaining Elements of 
Tissue ; the Tissues of the Body 
— Tissues composed of Simple 
Cells, with Fluid Intermediate 
Substance, Tissues composed of 
Simple Cells, with a small amount 
of Solid Intermediate Substance, 
Tissues belonging to the Con- 
nective Substance Group, Tissues 
composed of Transformed and, 
as a rule, Cohering Cells, with 




Transverse Section 01 a Human Bone. 



Homogeneous, Scanty, and more or less Solid Intermediate Substance ; Composite Tissues 
Organs of the Body — Organs of the Vegetative Type, Organs of the Animal Group. 



The 



CONSERVATIVE SURGERY, as exhibited in remedying 

some of the Mechanical Causes that operate injuriously both in Health and 
Disease. With Illustrations. By Henry G. Davis, M. D., Member of the 
American Medical Association, etc., etc. 

I vol., 8vo, 315 pp. Cloth, $3. 

The author has enjoyed rare facilities for the study and treatment of certain classes of disease, 
and the records here presented to the profession are the gradual accumulation of over thirty years' 
investigation. 

"Dr. Davis, bringing 1 as he does to his specialty deem it worthy of a place in every physician's li- 
a great aptitude for the solution of mechanical prob- brary. The style is unpretending, but trenchant, 
lems, takes a high rank as an orthopedic surgeon, graphic, and, best of all, quite intelligible." — Medi- 
and his very practical contribution to the literature cal Record. 
of the subject is both valuable and opportune. We 



YELLOW FEVER A NAUTICAL DISEASE. Its 

Origin and Prevention. By John Gamgee. 

1 vol, 8vo, 207 pp. Cloth, $1.50. 



" The author discusses, with a vast array of clear 
and well-digested facts, the nature and prevention 
of yellow fever. The work is admirably written, 
and the author's theories plausible and well sus- 
tained by logical deductions from established facts." 
— Homoeopathic Times. 



" The theory is certainly shown to be a plausible 
one ; and every reader, whether he be convinced or 
not, can not but be interested, instructed, and set to 
thinking." — Lancet a?zd Clinic. 



12 



D. APPLE TON <S- CO.'S MEDICAL WORKS. 



Specimen of Illustration. 



CONTRIBUTIONS TO REPARATIVE SURGERY, show- 

ing its Application to the Treatment of Deformities, produced by Destruc- 
tive Disease or Injury ; Congenital Defects from Arrest or Excess of Devel- 
opment ; and Cicatricial Contractions following Burns. Illustrated by Thirty 
Cases and fine Engravings. By Gurdon Buck, M. D. 
i vol., 8vo, 237 pp. Cloth, $3. 

" There is no department of surgery where the ingenuity 
and skill of the surgeon are more severely taxed than when 
required to repair the damage sustained by the loss of parts, 
or to remove the disfigurement produced by destructive dis- 
ease or violence, or to remedy the deformities of congenital 
malformation. The results obtained in such cases within 
the last half-century are among the most satisfactory achieve- 
ments of modern surgery. The term ' Reparative Surgery ' 
chosen as the title of this volume, though it may, in a com- 
prehensive sense, be applied to the treatment of a great 
variety of lesions to which the body is liable, is, however, 
restricted in this work exclusively to what has fallen under 
the author's own observation, and has been subjected to the 
test of experience in his own practice. It largely embraces 
the treatment of lesions of the face, a region in which plastic 
surgery finds its most frequent and important applications. 
Another and no less important class of lesions will also be 
found to have occupied a large share of the author's atten- 
tion, viz., cicatricial contractions following burns. While 
these cases have a very strong claim upon our commisera- 
tion, and should stimulate us, as surgeons, to the greatest 
efforts for their relief, they have too often in the past been 
dismissed as hopelessly incurable. The satisfactory results 
obtained in the cases reported in this volume will encour- 
age other surgeons, we trust, to resort with greater hope- 
fulness in the future to operative interference. Accuracy 
of description and clearness of statement have been aimed 
at in the following pages ; and if, in his endeavor to attain 
this important end, (he author has incurred the reproach of 
tediousness, the difficulty of the task must be his apology." 
— Extract from Preface. 




THE CHEMISTRY OF COMMON LIFE. Illustrated 

with numerous Wood Engravings. By the late James F. W. Johnson, 
F. R. S., Professor of Chemistry in the University of Durham. A new 
edition, revised and brought down to the Present Time. By Arthur Her- 
bert Church, M. A., Oxon. 
Illustrated with Maps and numerous Engravings on Wood. In one vol., i2mo, 592 pp. $2. 

SUMMARY OF CONTENTS.— The Air we Breathe; the Water we Drink; the Soil we 
Cultivate; the Plant we Rear; the Bread we Eat; the Beef we Cook; the Beverages we Infuse ; 
the Sweets we Extract ; the Liquors we Ferment ; the Narcotics we Indulge in ; the Poisons we 
Select; the Odors we Enjoy; the Smells we Dislike; the Colors we Admire ; What we Breathe 
and Breathe for ; What, How, and Why we Digest ; the Body we Cherish ; the Circulation of 
Matter. 



THE TONIC TREATMENT OF SYPHILIS. By E. L. 

Keyes, A. M., M. D., Adjunct Professor of Surgery and Professor of Der- 
matology in the Bellevue Hospital Medical College, etc. 
1 vol., 8vo, 83 pp. Cloth, $1. 

" My studies in syphilitic blood have yielded results at once so gratifying to me, and so con- 
vincing as to the tonic influence of minute doses of mercury, that I feel impelled to lay this brief 
treatise before the medical public in support of a continuous treatment of syphilis by small (tonic) 
doses of mercury. . I believe that a general trial of the method will, in the long run, vindicate its 
excellence. ' ' — Extract from Preface. 



D. APPLETON &* CO/S MEDICAL WORKS. 



13 



A PRACTICAL TREATISE ON TUMORS OF THE 

MAMMARY GLAND : embracing their Histology, Pathology, Diagnosis, 
and Treatment. By Samuel W. Gross, A. M., M. D., Surgeon to, and 
Lecturer on Clinical Surgery in, the Jefferson Medical College Hospital 
and the Philadelphia Hospital, etc. 

In one handsome 8vo vol. of 246 pp., with 29 Illustrations. Cloth. $2.50. 

"The work opportunely supplies a real want, 
and is the result of accurate work, and we heartily 
recommend it to our readers as well worthy of care- 
ful study." — London Lancet. 

" We know of no book in the English language 
which attempts to cover the ground covered by this 
one — indeed, the author seems to be the first who has 
sought to handle the whole subject of mammary 
tumors in one systematic treatise. How he has suc- 
ceeded will best be seen by a study of the book itself. 
In the early chapters the classification and relative 
frequency of the various tumors, their evolution and 
transformations, and their etiology, are dealt with ; 
then each class is studied in a separate chapter, in 
which the result of the author's work is compared 
with that of others, and the general conclusions are 
drawn which give to the book its great practical 
value ; finally, a chapter is devoted to diagnosis, one 
to treatment, and one to the tumors in the mam- 
mary gland of the male." — New York Medical 
Journal. 

' ' We heartily commend this work to the profes- 
sion, knowing that those who study its pages will 
be well repaid and have a better understanding of 
what to the average practitioner is obscure and un- 
satisfactory." — Toledo Medical a?id Surgical Jour- 
nal. 

' ' Dr. Gross has produced a work of real and 
permanent value ; it is not overstating the truth to 
say that this little volume is probably the best con- 
tribution to medical science which the present year 
has brought forth. We believe that the author has 




Cystic Encephaloid Carcinoma. 

done what he has set out to do, viz. , constructed a 
systematic and strictly accurate treatise on mamman 
tumors, and brought to his task all the light afforded 
by the most recent investigations into their pathol- 
ogy." — St. Louis Clinical Record. 

" This book is a real contribution to our profes- 
sional literature ; and it comes from a source which 
commands our respect. The plan is very systematic 
and complete, and the student or practitioner alike 
will find exactly the information he seeks upon anj 
of the diseases which are incident to the mammaiy 
gland." — Obstetrical Gazette. 

' ' Altogether, the work is one of more than ordi 
nary interest to the surgeon, gynaecologist, and phy- 
sician." — Detroit Lancet. 



OUTLINES OF THE PATHOLOGY AND TREAT- 
MENT OF SYPHILIS AND ALLIED VENEREAL DISEASES. By 

Hermann von Zeissl, M. D., late Professor at the Imperial-Royal Univer- 
sity of Vienna. " Second edition, revised by Maximilian von Zeissl, M. D., 
Privat-Docent for Diseases of the Skin and Syphilis at the Irnperial-Royal 
University of Vienna. Authorized edition. Translated, with Notes, by H. 
Raphael, M. D., Attending Physician for Diseases of the Genito-Urinary 
Organs and Syphilis, Bellevue Hospital Out-patient Department, etc. 
8vo, 402 pages. Cloth, $4.00; sheep, $5.00. 



"We regard the book as an excellent text-book 
for student or physician, and hope to hear of its 
adoption as such In therapeutic detail, the rec- 
ommendations are all good." — Virginia MedicU 
Monthly, 

''-It is scarcely necessary to refer to the talented 
author of the above-named work, since his life-long 
labor as a teacher and writer upon venereal diseases 
has made him known and quoted wherever these af- 
fections exist and are treated." — Polyclinic. 

" The book is a most excellent one in every re- 
spect, and the translator has done his work well." — 
Columbus Medical Journal. 

" It is a most thorough and practical manual, and 
translator and publisher both have done well in their 
respective capacities in thus issuing it." — Medical 
Press oj Western New York. 



" Medical science suffered a severe loss when, in 
September, 18S4, Hermann von Zeissl died. Hap- 
pily for us, this master in his chosen specialty had 
embodied the results of his vast experience in a text- 
book on syphilis and venereal diseases and published 
it some years before his death. The book now be- 
fore us is a second edition of the former book, re- 
vised and in large part, rewritten by Maximilian von 
Zeissl, and issued in the original some seven months 
before the father's death. It is a masterly treatise 
and thoroughly practical. We can commend it co 
all who are interested in venereal subjects. . . . Dr. 
Raphael has made a smooth and readable transla- 
tion and has added much valuable matter to the book, 
adapting it to the use of American physicians. The 
chapter on galloping syphilis is entirely by him." — 
The New York Medical Journal. 



H 



D. APPLE TON &* CO.'S MEDICAL WORKS. 



EMERGENCIES, AND HOW TO TREAT THEM. 

The Etiology, Pathology, and Treatment of Accidents, Diseases, and Cases 
of Poisoning, which demand Prompt Action. Designed for Students and 
Practitioners of Medicine. By Joseph W. Howe, M. D., Clinical Profess- 
or of Surgery in the Medical Department of the University of New York, 

etc., etc. 

Fourth edition, revised. I vol., 8vo, 265 pp. Cloth, $2.50. 

' ' To the general practitioner in towns, villages, 
and in the country, where the aid and moral sup- 
port of a consultation can not be availed of, this 
volume will be recognized as a valuable help. We 
commend it to the profession." — Cincinnati Lancet 
and Observer. 

" The author wastes no words, but devotes him- 



self to the description of each disease as if the pa- 
tient were under his hands. Because it is a good 



book we recommend it most heartily to the profes- 
sion." — Boston Medical and Surgical Journal. 

' ' This work bears evidence of a thorough prac- 
tical acquaintance with the different branches of the 
profession. The author seems to possess a peculiar 
aptitude for imparting instruction as well as for 
simplifying tedious details. A careful perusal will 
amply repay the student and practitioner." — New 
York Medical Journal. 



Specimen of Illustration. 



A TREATISE ON THE DISEASES OF THE NERV- 
OUS SYSTEM. By William A. Hammond, M. D., Surgeon-General 
U. S. Army (retired list) ; Professor of Diseases of the Mind and Nervous 
System in the New York Post-Graduate Medical School and Hospital; 
Member of the American Neurological Association and of the New York 
Neurological Society ; of the New York County Medical Society, etc. 

With 112 Illustrations. Eighth 
edition, revised, corrected, 
and enlarged by the Addi- 
tion of a New Section on 
Certain Obscure Nervous 
Diseases. 8vo-, 945 pages. 
Cloth, $5.00; sheep, $6.00. 

The work has received the 
honor of a French translation 
by Dr. Labadie-Lagrave, of 
Paris, and an Italian transla- 
tion by Professor Diodato Bor- 
relli, of the Royal University, 
has gone through the press at 
Naples. 

" In the Buddhist faith the 
eight gates of purity are de- 
scribed as : 1. Correct ideas ; 2. 
Correct thoughts ; 3. Correct 
words ; 4. Correct works ; 5. 
Correct life ; 6. Correct endeav- 
ors ; 7. Correct judgment ; and 
8. Correct tranquillity. If Dr. 
Hammond has not attained the medical nirvana, and passed those eight gates of purity, he has at least 
realized the Euddhist beatitude : ' Much insight and education, self-control and pleasant speech ; and 
whatever word be well spoken, this is the greatest blessing.' At least, the thoughts and utterances of Dr. 
Hammond have been so appreciated by the medical profession of America and England that the work has 
already passed through eight editions since its first appearance in 1871. As now revised by the author 
and published by the Appletons, it constitutes decidedly the best work in the English language upon dis- 
eases of the nervous system." — Kansas City Medical Index. 

This excellent work has now been fifteen years ten anything but this one work, it would have been 




before the profession, its popularity being sufficient- 
ly evidenced by the fact that it has rapidly passed 
through eight editions."— College and Clinical Rec- 
ord. 

" This great work of the gifted author has now 
reached its' eighth edition. A work of this charac- 
ter that has, within fifteen years, gone through eight 
revisions needs but little commendation from us, 
being fully able to speak for itself. It is, like its au- 
thor, without a peer in the special line of medicine 
it takes up. ... If Dr. Hammond had never writ- 



a monument of learning that would have lasted for 
ages."— Kansas City Medical Record. 

"The author of this work justly congratulates 
himself that the various previous editions which 
have been called for have received the approval of 
the profession beyond that ever given to any other 
work of like scope and objects published in any part 
of the world. In order to maintain the high char- 
acter thus attributed to it by the best judges, he has 
subjected this edition to a thorough revision, and has 
added a new section treating of certain obscure dis- 






D. APPLETON &* CO.'S MEDICAL WORKS. 15 

eases of the nervous system, as tetany, Thomsen's Specimen n F Ii lustration. 

disease, miryachit, and kindred affections. In all flWf/t'f&MtiBaLi /■// 

respects we must place this treatise as the best in the M'fj ° --'.. 

language on the specialty to which it is devoted." — IllilllWywIm 

Medical and Surgical Reporter. 

"When a work has reached its eighth edition, • ^flMHnji/ '^''J.' 

the reviewer might as well keep quiet, as the book- 
buyer has already decided that a demand has been , \_ III 
met." — New York Medical Times. I *- ' P; \C 

"This volume has been received by the profes- hi 

sion ' to an extent beyond that ever given to any j 

other work of like scope and objects published in any .., v c' .> ,1 

part cf the world.' The present edition contains a 

section on ' Certain Obscure Diseases of the Nervous I'VV }\ 

System,' is thoroughly revised throughout, and sev- 
eral changes made, thereby increasing greatly its use- '> 
fulness." — Buffalo Medical and Surgical Journal. ■.=» , '; f .' , $/!," 

' ' The eighth edition of this work speaks for itself | ^ -., b 

in the fact of its existence. The talented author 
has carefully revised the previous editions, elaborat- 
ing many portions which subsequent experience and 
observation have made necessary. A section has 
also been added on certain obscure diseases of the ■ ! 

nervous system, comprising tetany, Thomsen's dis- ■■ " £ ^ 

ease, miryachit, and kindred affections. These sub- ' t t ^IL,) 

pets are treated, like others in the work, with a flIOlilll/v ' 

master-hand and with the pen of a ready ar.d enter- IlllllilWMilWBH M^ t '' ~,-?,o.V 

taining writer. The author made his reputation long iMltlliili™^^^ ' V - ' 

ago, and that he is able to maintain it his last effort lEjty'i ; ':( , '\\ ! . 1 ' ; l '"" ^•'■r'iJi 

w ill abundantly prove." — Medical Record. \Ll- ' 

CLINICAL LECTURES ON DISEASES OF THE 

NERVOUS SYSTEM. Delivered at the Bellevue Hospital Medical Col- 
lege. By William A. Hammond, M. D., Professor of Diseases of the Mind 
and Nervous System, etc. Edited, with Notes, by T. M. B. Cross, M. D., 
Assistant to the Chairs of Diseases of the Mind and Nervous System, etc. 
Tn one handsome volume of 300 pages. $3.50. 

These lectures have been reported in full, and, together with the histories of the cases, which 
were prepared by the editor after careful study and prolonged observation, constitute a clinical 
volume which, while it does not claim to be exhaustive, will nevertheless be found to contain 
many of the more important affections of the kind that are commonly met with in practice. 

As these lectures were intended especially for the benefit of students, the author has confined 
himself to a full consideration of the symptoms, causes, and treatment of each affection, without 
attempting to enter into the pathology or morbid anatomy. 

THE ANATOMY OF VERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 431 pp. Cloth, $2.50. 

" The present work is intended to provide students of comparative anatomy with a condensed 
statement of the most important facts relating to the structure of vertebrated animals which have 
hitherto been ascertained. The Vertebrata are distinguished from all other animals by the circum- 
stance that a transverse and vertical section of the body exhibits two cavities completely separated 
from one another by a partition. The dorsal cavity contains the cerebro-spinal nervous system ; 
the ventral, the alimentary canal, the heart, and usually a double chain of ganglia, which passes 
under the name of the 'sympathetic' It is probable that this sympathetic nervous system repre- 
sents, wholly or partially, the principal nervous system of the Annulosa and Mollusca. And, in 
any case, the central parts of the cerebro-spinnl nervous system, viz., the brain and the spinal 
cord, would appear to be unrepresented among invertebrated animals." — The Author. 

"This long-expected work will be cordially wel- It is enough to say that it realizes, in a remarkable 

corned by all students and teachers of Comparative degree, the anticipations which have been formed 

Anatomy as a compendious, reliable, and, notwith- of it ; and that it presents an extraordinary combi- 

standing its small dimensions, most comprehensive nation of wide, general views, with the clear, accu- 

guide on the subject of which it treats. To praise rate, and succinct statement of a prodigious number 

or to criticise the work of so accomplished a master of individual facts." — Nature. 
of his favorite science would be equally out of place. 



i6 



D. APPLE TON 6- CO.'S MEDICAL WORKS. 



A TREATISE ON ORAL DEFORMITIES, as a Branch 

oi Mechanical Surgery. By Norman W. Kingsley, M. D. S., D. D. S., 
President of the Board of Censors of the State of New York, late Dean of 
the New York College of Dentistry and Professor of Dental Art and Mech- 



anism, etc., etc. 

With over 350 Illustrations. 

Specimen of Illustration. 



One vol., 8vo. Cloth, $5; sheep, $6. 

' ' I have read with great pleasure and much 
profit your valuable ' Treatise on Oral Deformi- 
ties.' The work contains much original matter 
of great practical value, and is full of useful in- 
formation, which will be of great benefit to the 
profession."— Lewis A. Sayre, M. D., LL. D., 
Professor of 0}'thopedic Surgery and Clinical 
Surgery, Bellevue Hospital Medical College. 

' ' A casual glance at this work might impress 
the reader with the idea that its contents were of 
more practical value to the dentist than to the 
general practitioner or surgeon. But it is by no 
means a mere work on dentistry, although a prac- 
tical knowledge of the latter art seems to be es- 
sential to the carrying out of the author's views 
regarding the correction of the different varieties 
of oral deformities of which he treats. We would 
be doing injustice to the work did not we make 
particular reference to the masterly chapter on the 
treatment of fractures of the lower jaw. The 
whole subject is so thoroughly studied that noth- 
ing is left to be desired by any surgeon who wish- 
es to treat these fractures intelligently and success- 
fully. The work, as a whole, bears marks of 
originality in every section, and impresses the 
reader with the painstaking efforts of the author 
to get at the truth, and apply it in an ingenious 
and practical way to the wants of the general 
practitioner, the surgeon, and the dentist." — 
Medical Record. 



" The profession is to be congratulated on 
possessing so valuable an addition to its litera- 
ture, and the author to be unstintedly praised for his successful issue to an arduous undertaking. The work 
bears, in a word, every evidence of having been written leisurely and with care. . . ."—Dental Cosmos. 

" To the surgeon and general practitioner of medicine, as well as the dentist, its instruction will be 
found invaluable. It is clear in style, practical in its application, comprehensive in its illustrations, and so 
exhaustive that it is not likely to meet in these respects a rival."— William H. Dwinelle, A. M., M. D. 

" I consider it to be the most valuable work that has ever appeared in this country in any department 
of the science of dental surgery. . 

"There is no doubt of its great value to every man who wishes to study and practice this branch 
of surgery, and I hope it may be adopted as a text-book in every dental college, that the students may 
have the benefit of the great experience of the 




author. 

" It places many things between the covers of 
one book which heretofore I have been obliged to 
look for in many directions, and often without 
success."— Frank Abbot, M. D., Dean of the 
Nfiw York College of Dentistry. 

"The writer does not hesitate to express his 
belief that the chapters on the ' aesthetics of den- 
tistry' will be found of more practical value to 
the prosthetic dentist than all the other essays 
on this subject existent in the English language. 
... A perusal of its pages seems to compel the 
mind to advance in directions variously indi- 
cated ; so variously, indeed, that there is hardly 
a page of the book which does not contain some 
important truth, some pregnant hint, or some 
valuable conclusion." — Dental Miscellany. 

"I congratulate you on having written a 
book containing so much valuable and original 
matter. It will prove of value not only to den- 
tists, but also to surgeons and physicians." — 
Frank Hastings Hamilton, M. D., LL. D,., 
Professor of the Practice of Surgery with Opera- 
tions, and of Clinical Surgery in Bellevue Hos- 
pital Medical College. 



Specimen of Illustration. 




D. APPLE TON &- CO.'S MEDICAL WORKS. 



17 



THE BREATH, AND THE DISEASES WHICH GIVE 

IT A FETID ODOR. With Directions for Treatment. By Joseph W. 
Howe, M. D., Clinical Professor of Surgery in the Medical Department of 
the University of New York, etc. 

Second edition, revised and corrected. I vol., i2mo, 108 pp. Cloth, $1. 

" This little volume well deserves the attention 
of physicians, to whom we commend it most high- 
ly." — Chicago Medical Journal. 

" To any one suffering from the affection, either 
in his own person or in that of his intimate ac- 
quaintances, we can commend this volume as con- 
taining all that is known concerning the subject, set 



forth in a pleasant style." — Philadelphia Medical 
Times. 

" The author gives a succinct account of the dis- 
eased conditions in which a fetid breath is an im- 
portant symptom, with his method of treatment. 
We consider the work a real addition to medical lit- 
erature." — Cincinnati Medical Journal. 



ON THE BILE, JAUNDICE, AND BILIOUS DIS- 
EASES. By J. Wickham Legg, M. D., F. R. C. S., Assistant Physician to 
St. Bartholomew's Hospital, and Lecturer on Pathological Anatomy in the 
Medical School. 

In one volume, 8vo, 719 pp. With Illustrations in Chromo-lithography. Cloth, $6 ; sheep, $7. 



"... And let us turn — which we gladly do — to 
the mine of wealth which the volume itself contains, 
for it is the outcome of a vast deal of labor ; so 
great indeed, that one unfamiliar with it would be 
surprised at the number of facts and references 
which the book contains." — Medical Times and Ga- 
zette, London. 

" The book is an exceedingly good one, and, in 
some points, we doubt if it could be made better. 
. . . And we venture to say, after an attentive 
perusal of the whole, that any one who takes it 
in hand will derive from it both information and 
pleasure ; it gives such ample evidence of honest 
hard work, of wide reading, and an impartial at- 
tempt to state the case of jaundice, as it is known 
by observation up to the present date. The book 
will not only live, but be in the enjoyment of a vig- 
orous existence long after some of the more popular 
productions of the present age are buried, past all 
hope of resurrection." — London Medical Record. 

" This portly tome contains the fullest account 
of the subjects of which it treats in the English lan- 
guage. The historical, scientific, and practical de- 
tails are all equally well worked out, and together 
constitute a repertorium of knowledge which no 
practitioner can well d~> without. The illustrative 
chromo-lithographs are beyond all praise." — Edin- 
burgh Medical Journal. 



" Dr. Legg's treatise is a really great book, ex- 
hibiting immense industry and research, and full of 
valuable information." — American Journal of Med- 
ical Science. 

' ' It seems to us an exhaustive epitome of all 
that is known on the subject." — Philadelphia Medi- 
cal Times. 

"This volume is one which will command pro- 
fessional respect and attention. It is, perhaps, the 
most comprehensive and exhaustive treatise upon 
the subject treated ever published in the English 
language." — Maryland Medical Journal. 

" It is the work of one who has thoroughly stud- 
ied the subject, and who, when he finds the evi- 
dence conflicting on disputed points, has attempted 
to solve the problem by experiments and observa- 
tions of his own." — Practitioner, Londoti. 

"It is a valuable work of reference and a wel- 
come addition to medical literature. — Dublin Jour- 
nal of Medical Science. 

"... The reader is at once struck with the im- 
mense amount of research exhibited, the author 
having left unimproved no accessible source of in- 
formation connected with his subject. It is, indeed, 
a valuable book, and the best storehouse of knowl- 
edge in its department that we know of." — Pacific 
Medical and Surgical Journal. 



FIRST LINES OF THERAPEUTICS as Based on the 

Modes and the Processes of Healing, as occurring spontaneously in Dis- 
eases ; and on the Modes and the Processes of Dying as resulting naturally 
from Disease. In a Series of Lectures. By Alexander Harvey, M. A., 
M. D., Emeritus Professor of Materia Medica in the University of Aber- 



deen, etc., etc. 



1 vol., i2mo, 278 pp. Cloth, $1.50. 



'' If only it can get a fair hearing before the pro- 
fession it will be the means of aiding in the devel- 
opment of a therapeutics more rational than we 
now dream of. To medical students and practi- 
tioners of all sorts it will open up lines of thought 
and investigation of the utmost moment." — Detroit 
Lancet. 

2 



"We may say that, as a contribution to the 
philosophy of medicine, this treatise, -which may be 
profitably read during odd moments of leisure, has 
a happy method of statement and a refreshing free- 
dom from dogmatism." — New York Medical Rec- 
ord. 



iS 



D. APPLETON &° CO.S MEDICAL WORKS. 



THE SCIENCE AND ART OF MIDWIFERY. By 

William Thompson Lusk, M. A., M. D., Professor of Obstetrics and Dis- 
eases of Women and Children in the Bellevue Hospital Medical College ; 
Obstetric Surgeon to the Maternity and Emergency Hospitals ; and Gynae- 
cologist to the Bellevue Hospital. 
New edition. Revised and enlarged. ^ Complete in one volume, Svo, with 246 Illustrations. 

" It contains one of the best ex-v 



Cloth, $5.00; sheep, $6.00. 




positions of the obstetric science and 
practice of the day with which we 
are acquainted. Throughout the 
work the author shows an intimate 
acquaintance with the literature of 
obstetrics, and gives evidence of large 
practical experience, great discrimi- 
nation, and sound judgment. We 
heartily recommend the book as a 
full and clear exposition of obstetric 
science and safe guide to student and 
practitioner. " — London Lancet. 

' ' Professor Lusk's book presents 
the art of midwifery with all that 
modern science or earlier learning 
has contributed to it." — Medical 
Record, Aew York. 

"This book bears evidence on 
every page of being the result of 
patient and laborious research and 
great personal experience, united 
and harmonized by the true critical 
or scientific spirit, and we are con- 
vinced that the book wiil raise the 
general standard of obstetric knowl- 
edge both in his own country and 
in this. Whether for the student obliged to learn the theoretical part of midwifery, or for the busy prac- 
titioner seeking aid in face of practical difficulties, it is, in our opinion, the best modern work on mid- 
wifery in the English language." — Dublin Journal 0/ Medical Science. 



D'Outrepont's Method, modified by Scanzoni. 




Author's Modification of Tarnier's Forceps. 



" Dr. Lusk's style is clear, generally concise, and 
he has succeeded in putting in less than seven hun- 
dred pages the best exposition in the English lan- 
guage of obstetric science and art. The book will 
prove invaluable alike to the student and the prac- 
titioner." — American Practitioner. 

" Dr. Lusk's work is so comprehensive in design 
and so elaborate in execution that it must be recog- 
nized as having a status peculiarly its own among 
the text-books of midwifery in the English lan- 
guage." — New York Medical Journal. 

"The work is, perhaps, better adapted to the 
wants of the student as a text-book, and to the 
practitioner as a work of reference, than any other 
one publication on the subject. It contains about 
all that is known of the ars obstetrica, and must 
add greatly to both the fame and fortune of the 
distinguished author." — Medical Herald, Louis- 
ville. 



"Dr. Lusk's book is eminently viable. It can 
not fail to live and obtain the honor of a second, a 
third, and nobody can foretell how many editions. 
It is the mature product of great industry and acute 
observation. It is by far the most learned and most 
complete exposition of the science and art of obstet- 
rics written in the English language. It is a book 
so rich in scientific and practical information, that 
nobody practicing obstetrics ought to deprive him- 
self of the advantage he is sure to gain from a fre- 
quent recourse to its pages." — American Journal of 
Obstetrics. 

"It is a pleasure to read such a book as that 
which Dr. Lusk has prepared ; everything pertain- 
ing to the important subject of obstetrics is dis- 
cussed in a masterly and captivating manner. We 
recommend the book as an excellent one, and feel 
confident that those who read it will be amply re- 
paid."— Obstetric Gazette, Cincinnati. 



D. APPLETON & CO.'S MEDICAL WORKS. 



r 9 



THE METHODS OF BACTERIOLOGICAL INVESTI- 
GATION. By Ferdinand Hueppe, Docent in Hygiene and Bacteriology 
in the Chemical Laboratory of R. Fresenius, at Wiesbaden. Written at the 
request of Dr. Robert Koch. Translated by Hermann M. Biggs, M. D., 
Instructor in the Carnegie Laboratory, and Assistant to the Chair of Patho- 
logical Anatomy in Bellevue Hospital Medical College. 
8vo, 218 pp. With 31 Illustrations. Cloth, $2.50. 

'* This is the best book so far available in Eng- of author, and is one which no student of pathol- 

iish, being better adapted to the general student who ogy can afford to be without. The translatkn 

undertakes the study from first principles." — North seems to have been most acceptably made."— Medi- 

Carolina Medical Journal. cal Press of Western New York. 

" All students of bacteriology will at once place « , Qf the m works that have rece ntly appeared 

this volume on their tables as indispensable for their on the subject of bacterial technology, this one cc-r- 

most accurate and rapid study."— American Lancet. tainly meets the requirem ents of a practical guide 

"The work is written by one who thoroughly and book of reference ; . . . the merits of the work 

understands his subject and puts it clearly before the are decided, and should secure for it the reputation 

student."— Pacific Medical and Surgical Journal it deserves." —Atlanta Medical and Surgical 

and Western Lancet. Journal. 

"He has sifted the whole of the scattered and "The book treats the subject in an exceedingly 

sometimes almost inaccessible literature of the sub- c i ear a ~d comprehensive manner, and leaves little to 

ject, and has furnished the independent investigator b e desired by the beginner, and is a complete guide 

a most valuable book, useful alike to the practitioner to t h OS e wishing to work out any of the innumerable 

and to the student, as a trustworthy introduction problems connected with the life-history of the 

into this territory. "—College and Clinical Record. bacteria. . . . The translation ssems to be well 

" To those who wish to have more than a mere done."— American Journal of the Medical Sciences. 

5ff£ SnS^ab^-]SS/^r UaI '^he importance of this subject in the scientific 

H world . . . should insure fcr so practical a presen- 

" As a whole, the book, written at Professor tation of it as is found in the present volume a wide 

Koch's request, reflects credit on the master's choice popularity." — New Etigland Medical Gazette. 

HEALTH PRIMERS. Edited by J. Langdon Down, M. D., 
F. R. C. P. ; Henry Power, M. B., F. R. C. S. ; J. Mortimer-Granville, 
M. D. ; John Tweedy, F. R. C. S. 

In square i6mo volumes. Cloth, 40 cents each. 

Though it is of the greatest importance that books upon health should be in the highest degree 
trustworthy, it is notorious that most of the cheap and popular kind are mere crude compilations 
of incompetent persons, and are often misleading and injurious. Impressed by these considera- 
tions, several eminent medical and scientific men of London .have combined to prepare a series of 
Health Primers of a character that shall be entitled to the fullest confidence. They are to be 
brief, simple, and elementary in statement, filled with substantial and useful information suitable 
for the guidance of grown-up people. Each primer will be written by a gentleman specially com- 
petent to treat his subject, while the critical supervision of the books is in the hands of a commit- 
tee who will act as editors. 

As these little books are produced by English authors, they are naturally based very much 
upon English experience, but it matters little whence illustrations upon such subjects are drawn, 
because the essential conditions of avoiding disease and preserving health are to a great degree 
everywhere the same. 

Volumes now ready. 

I. Exercise and Training. 

II. Alcohol : its Use and Abuse. 

III. Premature Death : its Promotion and Prevention. 

IV. The House and its Surroundings. 

V. Personal Appearance in Health and Disease. 
VI. Baths and Bathing. 
VII. The Skin and its Troubles. 

VIII. The Heart and its Functions. * 

IX. The Nervous System. 



20 D. APPLETON &* CO.'S MEDICAL WORKS. 

ANALYSIS OF THE URINE, with Special Reference to 

the Diseases of the Genito-Urinary Organs. By K. B. Hofmann, Pro- 
fessor in the University of Gratz, and R. Ultzmann, Docent in the Uni- 
versity of Vienna. Translated by T. Barton Brune, A. M., M. D., late 
Professor of the Practice of Medicine in the Baltimore Polyclinic and Post- 
Graduate Medical School, etc., and H. Holbrook Curtis, Ph. B., M. D., 
Fellow of the New York Academy of Medicine, etc. 
Second edition, revised and enlarged. With 8 Lithographic Plates. 8vo, 310 pp. Cloth, $2.00. 

4 ' Hofmann and Ultzmann's popular work on latest advances in urinary analysis. All unnecessary 

the urine needs neither criticism nor recommenda- matter has been eliminated, and the chemistry is so 

tion. Its claims have been substantiated in the simple as to be within the comprehension of all. 

offices of thousands of physicians both in Europe The translators have made a few additions which 

and America. It covers the entire field of chemical are practical and therefore useful." — Canada Lan- 

and microscopical examination of urine so far as cet. 
diagnosis is concerned, giving explicit directions as 

to details of manipulation."— Hahnemannian. This work has long been standard authority. 

But the late advances in urinology have made it ne- 

" Possessed of this book, a few reagents, a mi- cessary for the American translators practically to 

croscope with glasses powerful enough to magnify become editors of a new or second edition. They 

two or three hundred diameters, and a few test- have done their work well, and in this volume pre- 

tubes and slides, there is no good reason why every sent the profession with a reliable, practical book, 

physician should not become a good urinary ana- giving the most advanced ideas as to urinalysis and 

lyst."— Mississippi Valley Medical Monthly. diagnosis of urinary troubles in simple language, 

uv^^ _*,--«, ^„„,„,,„+o ~( tu +•*.• which does not require a mastery of clinical tech- 

k^^5S^ri^2S*SS^S nolo^.oundersta^d.-K^^^/^^. 

Hofmann and Ultzmann's work. . . . The second " In the present edition all unnecessary matter 

edition contains all the important advances that has b( en eliminated, and the translators have incor- 

have been made in the examination of the urinary porated all that has recently been added to our 

constituents during the past three years. One of knowledge of the subject that will be of especial in- 

the most important sections of the work is that de- terest to the student and practitioner. A valuable 

voted to an account of the microscopical and clinical feature of the book is the illustrations, which are 

aids for the diagnosis of the different forms of albu- very fine indeed."— Indiana Medical Journal. 

minuria. The translators are to be congratulated „ ,, , . , . . ' . 

on producing a very clear and readable rendering of , Students and general practitioners can ask no 

the original."— Canada Medical and Surgical better working guide on the subjects treated than 

journal. tnis standard work. The publishers present it in a 

handsome and durable form, and the colored plates 

"The second edition of this classical work on are uncommonly finished and fine." — New England 

the urine will be welcomed as containing all the Medical Gazette. 

CLINICAL ELECTRO-THERAPEUTICS. (Medical and 

Surgical.) A Manual for Physicians for the Treatment more especially of 

Nervous Diseases. By Allan McLane Hamilton, M. D., Physician in 

charge of the New York State Hospital for Diseases of the Nervous System, 

etc., etc. 

With numerous Illustrations. I vol., 8vo. Cloth, $2. 

This work is the compilation of well-tried measures and reported cases, and is intended as a 
simple guide for the general practitioner. It is as free from confusing theories, technical terms, 
and unproved statements as possible. Electricity is indorsed as a very valuable remedy in certain 
diseases, and as an invaluable therapeutical means in nearly all forms of Nervous Disease; but 
not as a specific for every human ill, mental and physical. 

THE ANATOMY OF INVERTEBRATED ANIMALS. 

By Thomas Henry Huxley, LL. D., F. R. S. 

I vol., i2mo. Illustrated. 596 pp. Cloth, $2.50. 

" My object in writing the book has been to make it useful to those who wish to become ac- 
quainted with the broad outlines of what is at present known of the morphology of the Inverte- 
brata ; though I have not avoided the incidental mention of facts connected with their physiology 
and their distribution. On the other hand, I have abstained from discussing questions of etiol- 
ogy, not because I underestimate their importance, or am insensible to the interest of the great 
problem of evolution, but because, to my mind, the growing tendency to mix up etiological specu- 
lations with morphological generalizations will, if unchecked, throw biology into confusion." — 
From Preface. 



D. APPLETON &> CO.'S MEDICAL WORKS. 



21 



HAND-BOOK OF SKIN DISEASES. By Dr. Isidor 

Neumann, Lecturer on Skin Diseases in the Royal University of Vienna. 

Translated from the German, second edition, with Notes, by Lucius D. 

Bulkley, A. M., M. D., Surgeon to the New York Dispensary, Department 

of Venereal and Skin Diseases ; Assistant to the Skin Clinic of the College 

of Physicians and Surgeons, New York, etc., etc. 

i vol., 8vo, 467 pp., and 66 Woodcuts. Cloth, $4; sheep, $5. 

Professor Neumann ranks sec- 
ond only to Hebra, whose assist- 
ant he was for many years, and his 
work may be considered as a fair 
exponent of the German practice 
of Dermatology. The book is 
abundantly illustrated with plates 
of the histology and pathology of 
the skin'. The translator has en- 
deavored, by means of notes from 
French, English, and American 
sources, to make the work valua- 
ble to the student as well as to the 
practitioner. 



" It is a work which I shall hear' i- 
ly recommend to my class of students 
at the University of Pennsylvania, 
and one which I feel sure will do 
much toward enlightening the pro- 
fession on this subject." — Louis A. 
Duhring. 

" There certainly is no work ex- 
tant which deals so thoroughly with 
the Pathological Anatomy of the Skin 
as does this hand-book." — New York 
Medical Record. 







"I have already twice expressed 
my favorable opinion of the book in f, 
print, and am glad that it is given to 
the public at last." — James C. White, 
Boston. 



"More than two years ago we 
noticed Dr. Neumann's admirable 
work in its original shape, and we are 
therefore absolved from the necessity 
of saying more than to repeat our 
strong recommendation of it to Eng- 
lish readers." — Practitioner. 




met 

WSs§ 



Lichen scrofulosorum. 



THE PATHOLOGY OF MIND. Being the third edition 

of the Second Part of the "Physiology and Pathology of Mind," recast, 
enlarged, and rewritten. By Henry Maudsley, M. D., London. 
I vol., l2mo, 580 pp. $2. 

CONTENTS. — Chapter I. Sleeping and Dreaming; II. Hypnotism, Somnambulism, and 
Allied States ; III. The Causation and Prevention of Insanity : ( A) Etiological; IV. The same 
continued; V. The Causation and Prevention of Insanity : (B; Pathological; VI. The Insanity of 
Early Life; VII. The Symptomatology of Insanity; VIII. The same continued; IX. Clinical 
Groups of Mental Disease ; X. The Morbid Anatomy of Mental Derangement ; XL The Treat- 
ment of Mental Disorders. 

The new material includes chapters on " Dreaming," " Somnambulism and its Allied States," 
and large additions in the chapters on the " Causation and Prevention of Insanity." 

"Unquestionably one of the ablest and most "Dr. Maudsley has had the courage to under- 

important works on the subject of which it treats take, and the skill to execute, what is, at least in 
that has ever appeared, and does credit to his philo- English, an original enterprise." — London Satur- 
sophical acumen and accurate observation." — Medi- day Review, 
cal Record. 



22 



D. APPLETON &* CO.'S MEDICAL WORKS. 



MEDICAL RECOLLECTIONS OF THE ARMY OF 

THE POTOMAC. By Jonathan Letterman, M. D., late Surgeon 
U. S. A., and Medical Director of the Army of the Potomac. 
i vol., 8vo, 194 pp. Cloth, $1. 



" We venture to assert that but few who open 
this volume of medical annals, pregnant as they are 



with instruction, will care to do otherwise than 
finish them at a sitting." — Medical Record. 



RESPONSIBILITY IN MENTAL DISEASES. By 



Henry Maudsley, M. D., London. 

1 vol., i2mo, 313 pp 

' ' This book is a compact presentation of those 
facts and principles which require to be taken into 
account in estimating human responsibility — not le- 
gal responsibility merely, but responsibility for con- 
duct in the family, the school, and all phases of 



Cloth, $1.50. 

social relation, in which obligation enters as an 
element. The work is new in plan, and was writ- 
ten to supply a wide-felt want which has not hither- 
to been met." — The Popular Science Monthly. 



BODY AND MIND: An Inquiry into their Connection and 

Mutual Influence, especially in reference to Mental Disorders; an enlarged 
and revised edition, to which are added Psychological Essays. By Henry 
Maudsley, M. D., London. 

I vol., i2mo, 275 pp. Cloth, $1.50. 

The general plan of this work may be described as being to bring man, both in his physical 
and mental relations, as much as possible within the scope of scientific inquiry. 

the abundant cases compiled by the medical author- 
ities ; but the physician, on the other hand, had no 
theoretical clew to his observations beyond a smat- 
tering of dogmatic psychology learned at college. 
To effect a reconciliation between the Psychology 
and the Pathology of the mind, or rather to con- 
struct a basis for both in a common science, is the 
aim of Dr. Maudsley's book." — London Saturday 
Review. 



" Dr. Maudsley has had the courage to under- 
take, and the skill to execute, what is, at least in 
English, an original enterprise. This book is a 
manual of mental science in all its parts, embracing 
all that is known in the existing state of physiology. 
. . . Many and valuable books have been written 
by English physicians on insanity, idiocy, and all 
the forms of mental aberration. But derangement 
had always been treated as a distinct subject, and 
therefore empirically. That the phenomena of 
sound and unsound minds are not matters of dis- 
tinct investigation, but inseparable parts of one and 
the same inquiry, seems a truism as soon as stated. 
But, strange to say, they had always been pursued 
separately, and been in the hands of two distinct 
classes of investigators. The logicians and meta- 
physicians occasionally borrowed a stray fact from 



"A representative work, which everyone must 
study who desires to know what is doing in the way 
of real progress, and not mere chatter, about men- 
tal physiology and pathology." — Lancet. 

"It distinctly marks a step in the progress of 
scientific psychology." — The Practitioner. 



HEALTH, AND HOW TO PROMOTE IT. By Richard 

McSherry, M. D., Professor of Practice of Medicine, University of Mary- 
land ; President of Baltimore Academy of Medicine, etc. 

1 vol., i2mo, 185 pp. Cloth, $1.25. 



" An admirable production which should find its 
way into every family in the country. It comprises 
a vast amount of the most valuable matter expressed 
in clear and terse language, and the subjects of 
which it treats are of the deepest interest to every 
human being. "—Prof. S. D. Gross, of Jefferson 
Medical College, Philadelphia. 

" On the whole, this little book seems to us very 
well adapted to its purpose, and will, we hope, have 
a wide circulation, when it can not fail to do much 
good." — American Journal of Medical Sciences. 

"It is the work of an able physician, and is 
written in a style which all people can understand. 
It deals with practical topics, and its ideas are set 
forth so pointedly as to make an impression." — 
The Independent. 



" This is a racy little book of 185 pages, full of 
good advice and important suggestions, and written 
in a free and easy style, which crops out in con- 
tinued humor and crispness by which the advice is 
seasoned, and which render the reading of the book 
a pleasant pastime to all, whether professionals or 
non-professionals." — Ca?zadian Journal of Medical 
Science. 

" It contains a great deal of useful information, 
stated in a very simple and attractive way." — Balti- 
niore Gazette. 

' ' This is one of the best popular essays on the 
subject we have ever seen. It is short, clear, posi- 
tive, sensible, bright and entertaining in its style, 
and is as full of practical suggestions as a nut is 
full of meat." — Literary World. 



D. APPLE TON &* CO.'S MEDICAL WORKS. 



23 



THE PHYSIOLOGY OF THE MIND. Being the First 

Part of a third edition, revised, enlarged, and in a great part rewritten, of 

" The Physiology and Pathology of the Mind." By Henry Maudsley, 

M. D., London. 

I vol., i2mo, 547 pp. Cloth, $2. 

CONTENTS.— Chapter I. On the Method of the Study of the Mind; II. The Mind and the 
Nervous System; III. The Spinal Cord, or Tertiary Nervous Centers; or, Nervous Centers of 
Reflex Action ; IV. Secondary Nervous Centers, or Sensory Ganglia ; Sensorium Commune ; V. 
Hemispherical Ganglia; Cortical Cells of the Cerebral Hemispheres; Ideational Nervous Cen- 
ters; Primary Nervous Centers; Intellectorium Commune; VI. The Emotions ; VII. Volition ; 
VIII. Motor Nervous Centers, or Motorium Commune and Actuation or Effection ; IX. Memory 
and Imagination. 



" The ' Physiology of the Mind,' by Dr. Mauds- 
ley, is a very engaging volume to read, as it is afresh 
and vigorous statement of the doctrines of a grow- 
ing scientific school on a subject of transcendent 
moment, and, besides many new facts and impor- 
tant views brought out in the text, is enriched by an 



instructive display of notes and quotations from 
authoritative writers upon physiology and psychol- 
ogy ; and by illustrative cases, which add materi- 
ally to the interest of the book." — Popular Science 
Monthly. 



PHYSICAL EDUCATION ; or, THE HEALTH LAWS 

OF NATURE. By Felix L. Oswald, M. D. 

l2mo, cloth. $1. 



"Dr. Oswald is a medical man of thorough 
preparation and large professional experience, and 
an extensively traveled student of nature and of 
men. While in charge of a military hospital at 
Vera Cruz, his own health broke down from long 
exposure in a malarial region, and he then struck 
for the Mexican mountains, where he became direct- 
or of another medical establishment. He has also 
journeyed extensively in Europe, South America, 
and the United States, and a] ways as an open-eyed, 
absorbed observer of nature and of men. The 
' Physical Education ' is one of the most whole- 
some and valuable books that have emanated from 
the American press in many a day. Not only can 
everybody understand it, and, what is more, feel it, 
but everybody that gets it will be certain to read and 
re-read it. We have known of the positive and 
most salutary influence of the papers as they ap- 
peared in the ' Monthly,' and the extensive demand 
for their publication in a separate form shows how 
they have been appreciated. Let those who are able 
and wish to do good buy it wholesale and give it to 
those less able to obtain it."' — The Popular Science 
Monthly. 

" Here we have an intelligent and sensible treat- 
ment of a subject of great importance, viz., physi- 
cal education. We give the headings of some of 
the chapters, viz. : Diet ; In-door Life ; Out-door 
Life ; Gymnastics ; Clothing ; Sleep ; Recreation ; 
Remedial Education ; Hygienic Precautions ; Pop- 
ular Fallacies. These topics are discussed in a plain, 
common-sense style suited to the popular mind. 



Books of this character can not be too widely read." 

— Albany (N. Y.) Argus. 

"Dr. Oswald is as epigrammatic as Emerson, 
as spicy as Montaigne, and as caustic as Heine. 
And yet he is a pronounced vegetarian. His first 
chapter is devoted to a consideration of the diet 
suitable for human beings and infants. In the next 
two he contrasts life in and out of doors. He then 
gives his ideas on the subjects of gymnastics, cloth- 
ing, sleep, and recreation. He suggests a system of 
remedial education and hygienic precautions, and 
he closes with a diatribe against popular fallacies." 
— Philadelphia Press. 

" It is a good sign that books on physical train- 
ing multiply in this age of mental straining. Dr. 
Felix L. Oswald, author of the above book, may be 
somewhat sweeping in his statements and beliefs, 
but every writer who, like him, clamors for sim- 
plicity, naturalness, and frugality in diet, for fresh 
air and copious exercise, is a benefactor. Let the 
dyspeptic and those who are always troubling them- 
selves and their friends about their manifold ail- 
ments take Dr. Oswald's advice and look more to 
their aliments and their exercise." — New York 
Herald. 

" One of the best books that can be put in the 
hands of young men and women. It is very inter- 
esting, full of facts and wise suggestions. It points 
out needed reforms, and the way we can become a 
strong and healthy people. It deserves a wide cir- 
culation." — Boston Commonwealth. 



GALVANO -THERAPEUTICS. The Physiological and 

Therapeutical Action of the Galvanic Current upon the Acoustic, Optic, 

Sympathetic, and Pneumogastric Nerves. By William B. Neftel. 

Fourth edition. I vol.. i2mo, 161 pp. Cloth, $1.50. 

This book has been republished at the request of several aural surgeons and other professional 
gentlemen, and is a valuable treatise on the subjects of which it treats. Its author, formerly visit- 
ing physician to the largest hospital of St. Petersburg, has had the very best facilities for investi- 
gation. 



' ' This little work shows, as far as it goes, full 
knowledge of what has been done on the subjects 
treated of, and the author's practical acquaintance 
with them." — New York Medical Journal. 



' ' Those who use electricity should get this work, 
and those who do not should peruse it to learn that 
there is one more therapeutical agent that they could 
and should possess." — The Medical Investigator. 



24 



D. APPLE TON &* CO.'S MEDICAL WORKS. 



OVARIAN TUMORS ; their Pathology, Diagnosis, and Treat- 
ment, with Reference especially to Ovariotomy. By E. R. Peaslee, M. D., 
Professor of Diseases of Women in Dartmouth College ; formerly Professor 
of Obstetrics and Diseases of Women in the New York Medical College, etc. 

I vol., 8vo, 551 pp. Illustrated with many Woodcuts, and a Steel Engraving of Dr. E. McDow- 
ell, the "Father of Ovariotomy." Cloth, $5; sheep, $6. 

This valuable work, embracing the results of many years of successful experience in the de- 
partment of which it treats, will prove most acceptable to the entire profession ; while the high 
standing of the author and his knowledge of the subject combine to make the book the best in the 
language. Fully illustrated, and abounding with information, the result of a prolonged study of 
the subject, the work should be in the hands of every physician in the country. 

' ' In closing our review of this work, we can not 
avoid again expressing our appreciation of the thor- 
ough study, the careful and honest statements, and 
candid spirit, which characterize it. For the use of 
the student we should give the preference to Dr. 
Peaslee 's work, not only from its completeness, but 
from its more methodical arrangement." — Ameri- 
can Journal of Medical Sciences. 



"We deem its careful perusal indispensable to 
all who would treat ovarian tumors with a good con- 
science." — American Journal of Obstetrics. 

' ' It shows prodigal industry, and embodies with- 
in its five hundred and odd pages pretty much all 
that seems worth knowing on the subject of ovarian 
diseases. " — Philadelphia Medical Times. 



A TREATISE ON DISEASES OF THE BONES. By 

Thomas M. Markoe, M. D., Professor of Surgery in the College of Physi- 
cians and Surgeons, New York, etc. With numerous Illustrations. 
1 vol., 8vo, 416 pp. Cloth, $4.50. 

Specimen of Illustration. This valuable work is a trea- 

tise on Diseases of the Bones, 
embracing their structural 
changes as affected by disease, 
their clinical history and treat- 
ment, including also an account 
of the various tumors which 
grow in or upon them. None 
of the injuries of bone are in- 
cluded in its scope, and no joint 
diseases, excepting where the 
condition of the bone is a prime 
factor in the problem of disease. 
As the work of an eminent sur- 
geon of large and varied experi- 
ence, it may be regarded as the best on the subject, and a valuable contribution to medical 
literature. 

DR. PEREIRA'S ELEMENTS OF MATERIA MEDICA 

AND THERAPEUTICS. Abridged and adapted for the Use of Medical 
and Pharmaceutical Practitioners and Students, and comprising all the 
Medicines of the British Pharmacopoeia, with such others as are frequently 
ordered in Prescriptions, or required by the Physician. Edited by Robert 
Bentley and Theophilus Redwood. 
New edition. Brought down to 1872. 1 vol., royal 8vo, 1,093 pp. Cloth, $7; sheep, $8. 




NOTES ON NURSING : What it is, and what it is not. By 

Florence Nightingale. 

I vol., i2mo, 140 pp. Cloth, 75 cents. 

These notes are meant to give hints for thought to those who have personal charge of the 
health of others. 

Every-day sanitary knowledge, or the knowledge of nursing, or, in other words, of how to put 
the constitution in such a state as that it will have no disease or that it can recover from disease, 
is recognized as the knowledge which every one ought to have — distinct from medical knowledge, 
which only a profession can have. 



D. APPLE TON &* CO.'S MEDICAL WORKS. 



25 



A TEXT-BOOK OF PRACTICAL MEDICINE. With 

Particular Reference to Physiology and Pathological Anatomy. By the 
late Dr. Felix von Niemeyer, Professor of Pathology and Therapeutics ; 
Director of the Medical Clinic of the University of Tubingen. Translated 
from the eighth German edition, by special permission of the author, by 
George H. Humphreys, M. D., one of the Physicians to Trinity Infirmary, 
Fellow of the New York Academy of Medicine, etc., and Charles E. 
Hackley, M. D., one of the Physicians to the New York Hospital and 
Trinity Infirmary, etc. 

Revised edition of 1880. 2 vols., 8vo, 1,628 pages. Cloth, $9; sheep, $11. 

The author undertakes, first, to give a picture of disease which shall be as life-like and faithful 
to nature as possible, instead of being a mere theoretical scheme ; secondly, so to utilize the more 
recent advances of pathological anatomy, physiology, and physiological chemistry, as to furnish a 
clearer insight into the various processes of disease. 

The work has met with the most flattering reception and deserved success ; has been adopted 
as a text-book in many of the medical colleges both in this country and in Europe ; and has re- 
ceived the very highest encomiums from the medical and secular press. 

unhesitatingly answer, ' It is ! ' " — New York Medi- 
cal Journal. 

" It is comprehensive and concise, and is char- 
acterized by clearness and originality. " — Dublin 
Quarterly Journal of Medicine. 

' ' Its author is learned in medical literature ; he 
has arranged his materials with care and judgment, 
and has thought over them." — The Lancet. 

"While, of course, we can not undertake a re- 
view of this immense work of about 1,600 pages in 
a journal of the size of ours, we may say that we 
have examined the volumes very carefully, as to 
whether to recommend them to practitioners or not ; 
and we are glad to say, after a careful review, ' Buy 
the book.' The chapters are succinctly written. 
Terse terms and, in the main, brief sentences are 
used. Personal experience is recorded, with a prop- 
er statement of facts and observations by other au- 
thors who are to be trusted. A very excellent index 
is added to the second volume, which helps very 
much for ready reference." — Virginia Medical 
Monthly. 



" This new American edition of Niemeyer fully 
sustains the reputation of previous ones, and may 
be considered, as to style and matter, superior to 
any translation that could have been made from the 
latest German edition. It will be recollected that 
since the death of Professor Niemeyer, in 1871, his 
work has been edited by Dr. Eugene Seitz. Although 
the latter gentleman has made many additions and 
changes, he has destroyed somewhat the individual- 
ity of the original. The American editors have 
wisely resolved to preserve the style of the author, 
and adhere, as closely as possible, to his individual 
views and his particular style. Extra articles have 
been inserted on chronic alcoholism, morphia-poi- 
soning, paralysis agitans, scleroderma, elephantiasis, 
progressive pernicious anaemia, and a chapter on 
yellow fever. The work is well printed as usual." 
— Medical Record. 

"The first inquiry in this country regarding a 
German book generally is, ' Is it a work of practi- 
cal value ? ' Without stopping to consider the just- 
ness of the American idea of the ' practical,' we can 



ESSAYS ON THE FLOATING MATTER OF THE 



AIR, in Relation to Putrefaction and Infection. 

DALL, F. R. S. 

l2mo. Cloth, $1.50. 



By Professor John Tyn- 



CONTENTS.—l. On Dust and Disease; II. Optical Deportment of the Atmosphere in Re- 
lation to Putrefaction and Infection; III. Further Researches on the Deportment and Vitality of 
Putrefactive Organisms ; IV. Fermentation, and its Bearings on Surgery and Medicine ; V. Spon- 
taneous Generation ; Appendix. 



"Professor TyndalTs book is a calm, patient, 
clear, and thorough treatment of all the questions 
and conditions of nature and society involved in 
this theme. The work is lucid and convincing, yet 
not prolix or pedantic, but popular and really en- 
joyable. It is worthy of patient and renewed 
study. " — Philadelphia Times. 

' ' The matter contained in this work is not only 
presented in a very interesting way, but is of great 
value." — Boston Journal of Commerce. 

"The germ theory of disease is most intelli- 
gently presented, and indeed the whole work is 
instinct with a high intellect." — Boston Coimnon- 
zvealth. 



" In the book before us we have the minute de- 
tails of hundreds of observations on infusions ex- 
posed to optically pure air ; infusions of mutton, 
beef, haddock, hay, turnip, liver, hare, rabbit, 
grouse, pheasant, salmon, cod, etc. ; infusions 
heated by boiling water and by boiling oil, some- 
times for a few moments and sometimes for several 
hours, and, however varied the mode of procedure, 
the result was invariably the same, with not even a 
shade of uncertainty. The fallacy of spontaneous 
generation and the probability of the germ theory 
of disease seem to us the inference, and the only 
inference, that can be drawn from the results, of 
nearly ten thousand experiments performed by Pro- 
fessor Tyndall within the last two years." — Pitts- 
burg Telegraph. 



26 



D. APPLETON &* CO.'S MEDICAL WORKS. 



THE APPLIED ANATOMY OF THE NERVOUS 

SYSTEM, being a Study of this Portion of the Human Body from a Stand- 
point of its General Interest and Practical Utility, designed for Use as a 
Text-book and as a Work of Reference. By Ambrose L. Ranney, A. M., 
M. D., Adjunct Professor of Anatomy and late Lecturer on the Diseases of 
the Genito-Urinary Organs and on Minor Surgery in the Medical Depart- 
ment of the University of the City of New York, etc., etc. 

I vol., 8vo. Profusely illustrated. Cloth, $4; sheep, $5. 




Distribution of the Hypo-glossal Nerve. 



" This is a useful book, and one of novel de- 
sign. It is especially valuable as bringing together 
facts and inferences which aid greatly in forming 
correct diagnoses in nervous diseases."— Boston 
Medical and Surgical Journal. 

"This is an excellent work, timely, practical, 
and well executed. It is safe to say that, besides 
Hammond's work, no book relating to the nervous 
system has hitherto been published in this country 
equal to the present volume, and nothing superior 
to it is accessible to the American practitioner."— 
Medical Herald. 

" There are many books, to be sure, which con- 
tain here and there hints in this field of great value 
to the physician, but it is Dr. Ranney's merit to 
have collected these scattered items of interest, and 
to have woven them into an harmonious whole, 
thereby producing a work of wide scope and of cor- 
respondingly wide usefulness to the practicing physi- 
cian. 

" The book, it will be perceived, is of an emi- 
nently practical character, and, as such, is addressed 
to those who can not afford the time for the perusal 
of the larger text-books, and who must read as they 
run." — New York Medical Journal. 



" Professors of anatomy in schools and colleges 
can not afford to be without it. We recommend 
the book to practitioners and students as well."— 
Virginia Medical Monthly. 

" It is an admitted fact that the subject treated 
of in this work is one sufficiently obscure to the pro- 
fession generally to make any work tending to elu- 
cidation most welcome. 

" We earnestly recommend this work as one un- 
usually worthy of study." — Buffalo Medical and 
Surgical Journal. 

"Dr. Ranney has firmly grasped the essential 
features of the results of the latest study of the 
nervous system. His work will do much toward 
popularizing this study in the profession. 

' ' We are sure that all our readers will be quite 
as much pleased as ourselves by its careful study." 
— Detroit Lancet. 

. "A useful and attractive book, suited to the 
time." — Louisville Medical News. 

"Our impressions of this work are highly fa- 
vorable as regards its practical value to students, as 
well as to educated medical men."— Pacific Medical 
and Surgical Journal. 



D. APPLETON &» CO.'S MEDICAL WORKS. 



27 



' ' The work shows great care in 
its preparation. We predict for it a 
large sale among the more progres- 
sive practitioners." — Michiga?i Medi- 
cal News. 

hl We are acquainted with no re- 
cent work which deals with the sub- 
ject so thoroughly as this ; hence, it 
should commend itself to a large class 
of persons, not merely specialists, but 
those who aspire to keep posted in 
all important advances in the science 
and art of medicine." — Maryland 
Medical Journal. 

' ' This work was originally ad- 
dressed to medical under-graduates, 
but it will be equally interesting and 
valuable to medical practitioners who 
still acknowledge themselves to be 
students. It is to be hoped that their 
number is not small." — New Orleans 
Medical and Surgical Journal. 

"We think the author has cor- 
rectly estimated the necessity for such 
a volume, and we congratulate him 
upon the manner in which he has 
executed his task. 

"Asa companion volume to the 
recent works on the diseases of the 
nervous system, it is issued in good 
time." — North Carolina Medical 
Journal. 

' ' A close and careful study of this 
work, we feel convinced, will impart 
to the student a large amount of practical knowledge which could not 
be gained elsewhere, except by wading through the enormous quan- 
tity of neurological literature which has appeared during past years, 
a task which few would have either time or inclination to accomplish. 
Here it will all be found condensed, simplified, and systematically 
arranged. The nature of the work is so fully explained in its title 
that little or nothing on that point need be said here. We will, how- 
ever, say that the whole subject is treated in a lucid manner, and that, 
so far as we are able to judge, nothing seems left out which could in 
any way improve or add to the value of the book." — Medical and 
Surgical Reporter (Philadelphia). 

' ' Dr. Ranney has done a most useful and praiseworthy task in 
that he will have saved many of the profession from the choice of 
going through the research we have indicated, or remaining in igno- 
rance of many things most essential to a sound medical knowledge." — Medical Record. 

"We are sure that this book will be well received, and will prove itself a very useful companion both 
for regular students of anatomy and physiology, and also for practitioners who wish to work up the diag- 
nosis of cases of disorder of the nervous system." — Canada Medical and Surgical Journal. 

" Dr. Ranney has done his work well, and given accurate information in a simple, readable style." — 
Philadelphia Medical Times. 




The Deep Branch of the External 
Plantar Nerve. 




The Small Sciatic Nerve, with its 
Branches of Distribution and 
Termination. 



A MINISTRY OF HEALTH AND OTHER AD 

DRESSES. By Dr. B. W. Richardson, M. D., M. A., F. R. S., etc., etc. 

I vol., l2mo, 354 pp. Cloth, $1.50. 



" The author is so widely and favorably known 
that any book which bears his name will receive re- 
spectful attention. He is one of those highly edu- 
cated yet practical, public-spirited gentlemen who 
adorn the profession of medicine and do far more 
than their share toward elevating its position before 
the public. This book, owing to the character of 
the matter considered and the author's attractive 
style, affords means for relaxation and instruction 
to everv thoughtful person." — Medical Gazette. 

" This book is made up of a number of addresses 
on sanitary subjects, which Dr. Richardson deliv- 
ered at various times in Great Britain, and which 
are intended to invite attention to the pressing re- 
forms that are making progress in medical science. 
The work, which has the great merit of being writ- 



ten in the simplest and clearest language, gives 
special attention to the origin and causes of diseases, 
and a demonstration of the physical laws by which 
they may be prevented. . . . 

" The author does not, like some members of his 
profession, enter into a learned description of cures, 
but traces the causes of diseases with philosophical 
precision. The book contains what every one should 
know, and members of the medical profession will 
not find a study of it in vain." — Philadelphia En- 
quirer. 

" The wide study of these lectures by both the 
profession and the laity would greatly advance the 
interests of both by stimulating thought and action 
respecting the most vital subjects that can engage 
the human mind." — Detroit Lancet. 



2 8 D. APPLETON <S- CO.'S MEDICAL WORKS. 

DISEASES OF MODERN LIFE. By Dr. B. W. Richard- 
son, M. D., M. A., F. R. S., etc., etc. 

I vol., i2mo, 520 pp. Cloth, $2. 

" In this valuable and deeply interesting work of atmospheric temperature, of atmospheric press- 

Dr. Richardson treats the nervous system as the ure, of moisture, winds, and atmospheric chemical 

very principle of life, and he shows how men do it changes, which are of great general interest." — Na- 

violence, yet expect immunity where the natural sen- ture. 
tence is death."— Charleston Courier. « Particular attention is given to diseases from 

"The work is of great value as a practical guide worry and mental strain, from the passions, from 

to enable the reader to detect and avoid various alcohol, tobacco, narcotics, food, impure air, late 

sources of disease, and it contains, in addition, sev- hours, and broken sleep, idleness, intermarriage, 

eral introductory chapters on natural life and natu- etc. , thus touching upon causes which do not enter 

ral death, the phenomena of disease, disease ante- into the consideration of sickness." — Boston Com- 

cedent to birth, and on the effects of the seasons, monwealth. 

THE WATERING-PLACES AND MINERAL SPRINGS 

OF GERMANY, AUSTRIA, AND SWITZERLAND. With Notes on 

Climatic Resorts and Consumption, Sanitariums, Peat, Mud, and Sand 

Baths, Whey and Grape Cures, etc. By Edward Gutmann, M. D 

With Illustrations, Comparative Tables, and a Colored Map, explaining the Situation and Chemi- 
cal Composition of the Spas. I vol., i2mo. Cloth, $2.50. 

'' Dr. Gutmann has compiled an excellent medi- tions, with the therapeutical applications of the 

cal guide, which gives full information on the man- mineral waters, are very thoroughly presented in 

ners and customs of living at all the principal separate parts of the volume." — New York Times. 
watering-places in Europe. The chemical composi- 

A PRACTICAL MANUAL ON THE TREATMENT 

OF CLUB-FOOT. By Lewis A. Sayre, M. D., Professor of Orthopedic 
Surgery and Clinical Surgery in Bellevue Hospital Medical College; Con- 
sulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 
Fourth edition, enlarged and corrected. I vol., i2mo. Illustrated. Cloth, $1.25. 

" A more extensive experience in the treatment of club-foot has proved that the doctrines taught 
in my first edition were correct, viz., that in all cases of congenital club-foot the treatment should 
commence at birth, as at that time there is generally no difficulty that can not be overcome by the 
ordinary family physician ; and that, by following the simple rules laid down in this volume, the 
great majority of cases can be relieved, and many cured, without any operation or surgical inter- 
ference. If this early treatment has been neglected, and the deformity has been permitted to in- 
crease by use of the foot in its abnormal position, surgical aid may be requisite to overcome the 
difficulty ; and I have here endeavored to clearly lay down the rules that should govern the treat- 
ment of this class of cases." — Preface. 

"The book will very well satisfy the wants of use, as stated, it is intended."— New York Medical 
the majority of general practitioners, for whose Journal. 

COMPENDIUM OF CHILDREN'S DISEASES. A 

Hand-Book for Practitioners and Students. By Dr. Johann Steiner, 
Professor of the Diseases of Children in the University of Prague. Trans- 
lated from the second German edition by Lawson Tait, F. R. C. S., Sur- 
geon to the Birmingham Hospital for Women. 

1 vol., 8vo. Cloth, $3.50; sheep, $4.50. 

"Dr. Steiner's book has met with such marked success in Germany that a second edition has 
already appeared, a circumstance v/hich has delayed the appearance of its English form, in order 
that I might be able to give his additions and corrections. 

" I have added as an Appendix the ' Rules for Management of Infants,' which have been issued 
by the staff of the Birmingham Sick Children's Hospital, because I think that they have set an ex- 
ample, by freely distributing these rules among the poor, for which they can not be sufficiently 
commended, and which it would be wise for other sick children's hospitals to follow. 

" I have also added a few notes, chiefly, of course, relating to the surgical ailments of chil- 
dren." — Extract from Translator's Preface. 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



2 9 



HEALTH : A Hand-Book for Households and Schools. By 

Edward Smith, M. D., F. R. S., Fellow of the Royal College of Physicians 

and Surgeons of England, etc. 

1 vol., i2mo. Illustrated. 198 pp. Cloth, $1. 

Tt is intended to inform the mind on the subjects involved in the word Health, to show how 
health may be retained and ill-health avoided, and to add to the pleasure and usefulness of life. 



" The author of this manual has rendered a real 
service to families and teachers. It is not a mere 
treatise on health, such as would be written by a 
medical professor for medical students. Nor is it 
a treatise on the treatment of disease, but a plain, 
common-sense essay on the prevention of most of 
the ills that flesh is heir to. There is no doubt that 
much of the sickness with which humanity is af- 
flicted is the result of ignorance, and proceeds from 



the use of improper food, from defective drainage, 
overcrowded rooms, ill-ventilated workshops, im- 
pure water, and other like preventable causes. 
Legislation and municipal regulations may do 
something in the line of prevention, but the people 
themselves can do a great deal more — particularly 
if properly enlightened ; and this is the purpose of 
the book." — Albany Journal. 



LECTURES ON ORTHOPEDIC SURGERY AND DIS- 
EASES OF THE JOINTS. By Lewis A. Sayre, M. D., Professor of 
Orthopedic Surgery and Clinical Surgery in Bellevue Hospital Medical Col- 
lege ; Consulting Surgeon to Bellevue Hospital, Charity Hospital, etc., etc. 

Second edition, revised and greatly enlarged, with 324 Illustrations. 1 vol., 8vo, 569 pp. Cloth, 

$5 ; sheep, $6. 

This edition has been thoroughly revised and rearranged, and the subjects classified in the ana- 
tomical and pathological order of their development. Many of the chapters have been entirely 
rewritten, and several new ones added, and the whole work brought up to the present time, with 
all the new improvements that have been developed in this department of surgery. Many new 
engravings have been added, each illustrating some special point in practice. 

Specimen of Illustration. 




' ' The name of the author is a sufficient guar- 
antee of its excellence, as no man in America or 
elsewhere has devoted such unremitting attention 
for the past thirty years to this department of Sur- 
gery, or given to the profession so many new truths 
and laws as applying to the pathology and treat- 
ment of deformities." — Western Lancet. 

" The name of Lewis A. Sayre is so intimately 
connected and identified with orthopaedics in all its 
branches, that a book relating his experience can 
not but form an epoch in medical science, and prove 
a blessing to the profession and humanity. Dr. 
Sayre's views on many points differ from those 
entertained by other surgeons, but the great suc- 
cesses he has obtained fully warrant him in main- 
taining the ' courage of his opinions.' " — American 
Journal of Obstetrics. 



" Dr. Sayre has stamped his individuality on 
every part of his book. Possessed of a taste for 
mechanics, he has admirably utilized it in so modi- 
fying the inventions of others as to make them of 
far greater practical value. The care, patience, and 
perseverance which he exhibits in fulfilling all the 
conditions necessary for success in the treatment of 
this troublesome class of cases are worthy of all 
praise and imitation." — Detroit Review of Medi- 
cine. 

"Its teaching is sound, and the originality 
throughout very pleasing ; in a word, no man 
should attempt the treatment of deformities of joint 
affections without being familiar with the views 
contained in these lectures." — Canada Medical and 
Surgical Journal. 



3° 



D. APPLETON &* CO.'S MEDICAL WORKS. 



LECTURES UPON DISEASES OF THE RECTUM 

AND THE SURGERY OF THE LOWER BOWEL. Delivered at 
the Bellevue Hospital Medical College by W. H. Van Buren, M. D., late 
Professor of the Principles and Practice of Surgery in the Bellevue Hospi- 
tal Medical College, etc., etc. 
Second edition, revised and enlarged. I volume, 8vo, 412 pp., with 27 Illustrations and complete 



Index. 

Specimen of Illustration. 



Cloth, 



)VO, 

$3; sheep," $4. 

1 ' The reviewer too often finds it a difficult 
task to discover points to praise, in order that 
his criticisms may not seem one-sided and un- 
just. These lectures, however, place him upon 
the other horn of the dilemma, viz., to find 
somewhat to criticise severely enough to clear 
himself of the charge of indiscriminating lau- 
dation. Of course, the author upholds some 
\ views which conflict with other authorities, but 

he substantiates them by the most powerful of 
ai-guments, viz., a large experience, the results 
of which are enunciaUd by one who elsewhere 
shows that he can appreciate, and accord the 
due value to, the work and experience of 
others. " — Archives of Medicine. 

" The present is a new volume rather than 
a new edition. Both its size and material 
are vastly beyond its predecessor. The same 
scholarly method, the same calm, convincing 
statement, the same wise, carefully matured 
counsel, pervade every paragraph. The dis- 
comfort and dangers of the diseases of the 
rectum call for greater consideration than 
they usually receive at the hands of the pro- 
fession." — Detroit Lancet. 

" These lectures are twelve in number, and 
may be taken as an excellent epitome of our 
present knowledge of the diseases of the parts 
in question. The work is full of practical 
matter, but it owes not a little of its value to 
the original thought, labor, and suggestions 
as to the treatment of disease, which always 
characterize the productions of the pen of Dr. 
Van Buren." — Philadelphia Medical Times. 

" The most attractive feature of the work 
is the plain, common-sense manner in which 
each subject is treated. The author has laid down instructions for the treatment, medicinal and opera- 
tive, of rectal diseases in so clear and lucid style as that any practitioner is enabled to follow it. The 
large and successful experience of the distinguished author in this class of diseases is sufficient of itself to 
warrant the high character of the book." — Nashville Journal of Medicine and Surgery. 

We have thus briefly tried to give the known to the profession as one of our most accom- 




reader an idea of the scope of this work : and the 
work is a good one — as good as either Allingham's 
or Curling's, with which it will inevitably be com- 
pared. Indeed, we should have been greatly sur- 
prised if any work from the pen of Dr. Van Buren 
had not been a good one ; and we have to thank 
him that for the first time we have an American 
text-book on this subject which equals those that 
have so long been the standards." — New York Med- 
ical Journal. 

' ' Mere praise of a book like this would be super- 
fluous — almost impertinent. The author is well 



plished surgeons and ablest scientific men. Much 
is expected of him in a book like the one before us, 
and those who read it will not be disappointed. Ic 
will, indeed, be widely read, and, in a short time, 
take its place as the standard American authority." 
— St. Louis Courier of Medicine. 

" Taken as a whole, the book is one of the most 
complete and reliable ones extant. It is certainly 
the best of any similar work from an American au- 
thor. It is handsomely bound and illustrated, and 
should be in the hands of every practitioner and 
student of medicine." — Lohisville Medical Herald. 



REPORTS. Bellevue and Charity Hospital Reports for 1870, 
containing valuable contributions from Isaac E. Taylor, M. D., Austin 
Flint, M. D., Lewis A. Sayre, M. D., William A. Hammond, M. D., T. 
Gaillard Thomas, M. D., Frank H. Hamilton, M. D., and others. 
1 vol., 8vo, 415 pp. Cloth, $4. 
" These institutions are the most important, as connected with them are acknowledged to be among 
regards accommodations for patients and variety of the first in their profession, and the volume is an 
•ases treated, of any on this continent, and are sur- important addition to the professional literature of 
passed by but few in the world. The gentlemen this country." — Psychological Journal. 



D. APPLE TON &* CO.'S MEDICAL WORKS. ^ T 

THE POSTHUMOUS WORKS OF SIR JAMES YOUNG 

SIMPSON, Bart., M. D. In Three Volumes. 
Volume I. — Selected Obstetrical and Gynaecological Works of Sir 
James Y. Simpson. Edited by J. Watt Black, M. D. 

I vol., 8vo, 852 pp. Cloth, $3 ; sheep, $4. 

This first volume contains many of the papers reprinted from his Obstetric Memoirs and Con- 
tributions, and also his Lecture Notes, now published for the first time, containing the substance 
of the practical part of his course of midwifery. It is a volume of great interest to the profession, 
and a fitting memorial of its renowned and talented author. 

Volume II. — Anaesthesia, Hospitalism, etc. 'Edited by Sir Walter Simp- 
son, Bart. 

"We say of this, as of the first volume, that it may be picked out and studied with pleasure and 
should find a place on the table of every practi- profit."— The Lancet {Lo?tdon). 
tioner ; for, although it is patchwork, each piece 

1 vol., 8vo, 560 pp. Cloth, $3 ; sheep, $4. 

Volume III. — Diseases of Women. Edited by Alexander Simpson, M. D. 

1 vol., 8vo, 789 pp. Cloth, $3 ; sheep, $4. 
One of the best works on the subject extant. Of inestimable value to every physician. 

ON FOODS. By Edward Smith, M. D., LL. B., F. R. S., 

Fellow of the Royal College of Physicians of London, etc., etc. 

I vol., i2mo, 485 pp. Cloth, $1.75. 

•' Since the issue of the author's work on ' Prac- " The book contains a series of diagrams, dis- 

tical Dietary,' he has felt the want of another, which playing the effects of sleep and meals on pulsation 

would embrace all the generally known and some and respiration, and of various kinds of food on 

less known foods, and contain the latest scientific respiration, which, as the results of Dr. Smith's own 

knowledge respecting them. The present volume is experiments, possess a very high value. We have 

intended to meet this want, and will be found use- not far to go in this work for occasions of favorable 

ful for reference, to both scientific and general criticism ; they occur throughout, but are perhaps 

readers. The author extends the ordinary view of most apparent in those parts of the subject with 

foods, and includes water and air, since they are which Dr. Smith's name is especially linked." — ■ 

important both in their food and sanitary aspects. London Examiner. 

A HAND-BOOK OF CHEMICAL TECHNOLOGY. 

By Rudolph Wagner, Ph. D., Professor of Chemical Technology at the 
University of Wurtzburg. Translated and edited, from the eighth German 
edition, with Extensive Additions, by William Crooks, F. R. S. 
With 336 Illustrations. I vol., 8vo, 761 pp. Cloth, $5. 

Under the head of Metallurgic Chemistry, the latest methods of preparing iron, cobalt, nickel, 
copper, copper-salts, lead and tin and their salts, bismuth, zinc, zinc-salts, cadmium, antimony, 
arsenic, mercury, platinum, silver, gold, manganates, aluminum, and magnesium, are described. 
The various applications of the voltaic current to electro-metallurgy follow under this division. 
The preparation of potash and soda-salts, the manufacture of sulphuric acid, and the recovery of 
sulphur from soda waste, of course occupy prominent places in the consideration of chemical manu- 
factures. It is difficult to overestimate the mercantile value of Mond's process, as well as the 
many new and important applications of bisulphide cf carbon. The manufacture of soap will be 
found to include much detail. The technology of glass, stone-ware, limes, and mortars will pre- 
sent much of interest to the builder and engineer. The technology of vegetable fibers has been 
considered to include the preparation of flax, hemp, cotton, as well as paper-making ; while the 
application of vegetable products will be found to include sugar-boiling, wine- and beer-brewing, 
the distillation of spirits, the baking of bread, the preparation of vinegar, the preservation of wood, 
etc. 

Dr. Wagner gives much information in reference to the production of potash from sugar-resi- 
dues. The use of baryta-salts is also fully described, as well as the preparation of sugar from 
beet-roots. Tanning, the preservation of meat, milk, etc., the preparation of phosphorus and ani- 
mal charcoal, are considered as belonging to the technology of animal products. The preparation 
of materials for dyeing has necessarily required much space ; while the final sections of the book 
have been devoted to the technology of heating and illumination. 



32 



D. APPLETON &* CO.'S MEDICAL WORKS. 



PRACTICAL TREATISE ON THE SURGICAL 

DISEASES OF THE GENITO-URINARY ORGANS, including 
Syphilis. Designed as a Manual for Students and Practitioners. With 
Engravings and Cases. By W. H. Van Buren, A. M., M. D., late Profess- 
or of Principles of Surgery, with Diseases of the Genito-Urinary System 
and Clinical Surgery, in Bellevue Hospital Medical College, etc., and E. I,. 
Keyes, A. M., M. D., Professor of Dermatology in Bellevue Hospital Medi- 
cal College; Surgeon to the Charity Hospital, Venereal Diseases, etc. 
i vol., 8vo, 672 pp. Cloth, $5; sheep, $6. 

it deals. These facts are largely drawn from 
the extensive and varied experience of the au- 
thors. 

Many important branches of genito-urinary 
diseases, as the cutaneous maladies of the penis 
and scrotum, receive a thorough and exhaustive 
treatment that the professional reader will search 
for elsewhere in vain. 

The subject of syphilis is included, of neces- 
sity, in this treatise. Although properly be- 
longing to the department of Frinciples of Sur- 
gery, there is no disease falling within the limits 
of this work concerning which clear and correct 
ideas as to nature and treatment will, at the 
present time, so seriously influence success in 
practice. 

The work is elegantly and profusely illus- 
trated, and enriched by fifty-five original cases, 
setting forth obscure and difficult points in diag- 
nosis and treatment. 

" The authors ' appear to have succeeded admi- 
rably in giving to the world an exhaustive and re- 
liable treatise on this important class of diseases.' " 
— Northwestern Medical and Sicrgical yournal. 

" It is a most complete digest of what has long 
been known, and of what has been more recently 
discovered, in the field of syphilitic and genito-urin- 
ary disorders. It is, perhaps, not all exaggeration 
to say that no single work upon the same subject 
has yet appeared, in this or any foreign language, 
which is superior to it.'" — Chicago Medical Exam- 
iner. 

' l The commanding reputation of Dr. Van Buren 
in this specialty, and of the great school and hos- 
pital from which he has drawn his clinical materials, 
together with the general interest which attaches to 
the subject-matter itself, will, we trust, lead very 
many of those for whcm it is our office to cater, to 
possess themselves at once of the volume and form 
their own opinions of its merit." — Atlanta Medical 
and Surgical Journal. 




Showing Enlarged Prostate with "Third Lobe," through 
the Base of which a False Passage has been made. 

This work is really a compendium of, and a 
book of reference to, all modern works treating 
in any way of the surgical diseases of the genito- 
urinary organs. At the same time, no other 
single book contains so large an array of original 
facts concerning the class of diseases with which 



A MANUAL OF MIDWIFERY. Including the Pathology 

of Pregnancy and the Puerperal State. By Dr. Carl Schroeder, Professor 
of Midwifery and Director of the Lying-in Institution in the University of 
Erlangen. Translated from the third German edition by Charles H. 
Carter, B. A., M. D., B. S., London, Member of the Royal College of 
Physicians, London. 
With Twenty-six Engravings on Wood. 1 vol., 8vo, 388 pp. Cloth, $3.50; sheep, $4.50. 
" The translator feels that no apology is needed in offering to the profession a translation of 
Schroeder's ' Manual of Midwifery.' The work is well known in Germany, and extensively used 
as a text-book ; it has already reached a third edition within the short space of two years, and it 
is hoped that the present translation will meet the want, long felt in this country, of a manual of 
midwifery embracing the latest scientific researches on the subject." 



D. APPLE TO W <5- CO.'S MEDICAL WORKS. 



33 



HOSPITALS : Their History, Organization, and Construction. 

Boylston Prize-Essay of Harvard University for 1876. By W. Gill Wylie, 
M. D. 1 vol., 8vo, 240 pp. Cloth, $2.50. 



A TREATISE ON CHEMISTRY. By H. R. Roscoe, 

F. R. S., and C. Schorlemmer, F. R. S., Professors of Chemistry in the 
Victoria University, Owens College, Manchester. Illustrated. 

INORGANIC CHEMISTRY. 8vo. Vol. I : Non-Metallic Elements. $5. 
Vol. II, Part I : Metals. $3. Vol. II, Part II : Metals. $3. 

ORGANIC CHEMISTRY. 8vo. Vol. Ill, Part I . The Chemistry of the 
Hydrocarbons and their Derivatives. $5. Vol. Ill, Part II, com- 
pleting the work : The Chemistry of the Hydrocarbons and their 
Derivatives. $5. 

" It has been the aim of the authors, in writing their present treatise, to place before the read- 
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at the same time entering so far into a discussion of chemical theory as the size of the work and the 
present transition state of the science will permit. 

*" Special attention has been paid to the accurate description of the more important processes 
in technical chemistry, and to the careful representation of the most approved forms of apparatus 
employed. 

" Much attention has likewise been given to the representation of apparatus adopted for lec- 
ture-room experiment, and the numerous new illustrations required for this purpose have all been 
taken from photographs of apparatus actually in use." — Extract from Preface. 



Specimen of Illustration. 




" The authors are evidently bent on making 
their book the finest systematic treatise on modern 
chemistry in the English language, an aim in which 
they, are well seconded by their publishers, who 
spare neither pains nor cost in illustrating and 
otherwise setting forth the work of these distin- 
guished chemists." — London Athenczum. 

" It is difficult to praise too highly the selection 
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of illustrations which explain and adorn the text. 
In its woodcuts, in its technological details, in its 
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der review presents most commendable features. 
Whatever tests of accuracy as to figures and facts 
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met, while in clearness of statement this volume 
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has been reached — no uncommon occurrence with 
elaborate treatises on natural science subjects." — 
London Academy. 

' ' We have no hesitation in saying that this vol- 
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connected with each product. It is this that lends 
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very much more than a mere text-book." — Satur- 
day Review. 



34 D. APPLETON &> CO.'S MEDICAL WORKS. 

THE BRAIN AND ITS FUNCTIONS. By J. Luys, 

Physician to the Hospice de la Salpetriere. 

With Illustrations. i2mo. Cloth, $1.50. 

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the anatomy of the nervous system are acknowl- ality." — Boston Evening Traveller. 
edged to be the fullest and most systematic ever un- 
dertaken."—^/. James's Gazette. u Dn Luys? at the head of the ^cU French In- 

" It is not too much to say that M. Luys has gone sane Asylum, is one of the most eminent and sue- 
further than any other investigator into this great cessful investigators of cerebral science now living ; 
field of study, and only those who are at least dimly and he has given unquestionably the clearest and 
aware of the vast changes going on in the realm of most interesting brief account yet made of the 
psychology can appreciate the importance of his structure and operations of the brain." — Popular 
revelations. Particularly interesting and valuable Science Monthly. 

GENERAL PHYSIOLOGY OF MUSCLES AND 

NERVES. By Dr. I. Rosenthal, Professor of Physiology at the Univer- 
sity of Erlangen. 

With 75 Woodcuts. l2mo. Cloth, $1.50. 

" Dr. Rosenthal claims that the present work is recondite as to be unprofitable or uninteresting to 

the ' first attempt at a connected account of general the inquiring general reader." — New York Ob- 

physiology of muscles and nerves.' This being the server. 

case, Dr. Rosenthal is entitled to the greatest credit « T n this volume an attempt is made to give a 

for his clear and accurate presentation of the ex- connected account of the general physiology of 

perimental data upon which must rest all future mU scles and nerves, a subject which has never be- 

knowledge of a very important branch of medical f ore had so thorough an exposition in any text- 

and electrical science. The book consists of 317 book, although it is one which has many points of 

pages, with seventy-five woodcuts, many of which interest for every cultivated man who seeks to be 

represent physiological apparatus devised by the we ji informed on all branches of the science of life. 

author or by his friends, Professor Du Bois-Rey- This work sets before its readers all, even the most 

mond and Helmholtz. It must be regarded as in- intricate, phases of its subject with such clearness of 

dispensable to all future courses of medical study." expression that any educated person though not a 

—New York Herald. specialist can comprehend it." — New Haven Palla- 

" Although this work is written for the instruc- dium. 
tion of students, it is by no means so technical and 

MEDICAL AND SURGICAL ASPECTS OF IN-KNEE 

(Genu-Valgum) : Its Relation to Rickets ; its Prevention ; and its Treat- 
ment, with or without Surgical Operation. By W. J. Little, M. D., F. R. 
C. P., late Senior Physician to and Lecturer on Medicine at the London 
Hospital; Visiting Physician to the Infant Orphan Asylum at Wanstead ; 
the Earlswood Asylum for Idiots ; Founder of the Royal Orthopaedic Hos- 
pital, etc. Assisted by E. Muirhead Little, M. R. C. S. 

One 8vo vol., containing 161 pages, with complete Index, and illustrated by upward of 50 Figures 

and Diagram?. Cloth, $2. 

A DICTIONARY OF MEDICINE, including General 

Pathology, General Therapeutics, Hygiene, and the Diseases peculiar to 

Women and Children. By Various Writers. Edited by Richard Quain, 

M. D., F. R. S., Fellow of the Royal College of Physicians; Member of the 

Senate of the University of London; Member of the General Council of 

Medical Education and Registration ; Consulting Physician to the Hospital 

for Consumption and Diseases of the Chest at Brompton, etc. 

In one large 8vo volume of 1,834 pages, and 138 Illustrations. Half morocco, $8. Sold only by 

subscription. 

This work is primarily a Dictionary of Medicine, in which the several diseases are fully dis- 
cussed in alphabetical order. The description of each includes an account of its etiology and ana- 
tomical characters; its symptoms, course, duration, and termination; its diagnosis, prognosis, 



D. APPLETON &• CO.'S MEDICAL WORKS. 



35 



and, lastly, its treatment. General Pathology comprehends articles on the origin,. characters, and 
nature of disease. 

General Therapeutics includes articles on the several classes of remedies, their modes of ac- 
tion, and on the methods of their use. The articles devoted to the subject of Hygiene treat of the 
causes and prevention of disease, of the agencies and laws affecting public health, of the means of 
preserving the health of the individual, of the construction and managemeiiLof hospitals, and of 
the nursing of the sick. 

Lastly, the diseases peculiar to women and children are discussed; under their respective head- 
ings, both in aggregate and in detail. 

Among the leading contributors, whose names at once strike the reader as affording a guaran- 
tee of the value of their contributions, are the following : 



Allbutt, T. Clifford, M. A., M. D. 

Barnes, Robert, M. D. 

Bastian, H. Charlton, M. A., M. D. 

Binz, Carl, M. D. 

Bristowe, J. Syer, M. D. 

Brown-Sequard, C. E., M. D., LL. D. 

Brunton, T. Lauder, M. D., D. Sc. 

Fayrer, Sir Joseph, K. C. S. I., M. D., LL. 

Fox, Tilbury, M. D. 

Galton, Captain Douglas, R. E. (retired). 

Gowers, W. R., M. D. 



G reenfleld,„ W.. S. ,. . M. IX 

Jenner, Sir William, tart., K. C. B M M. D. 

Legg, J. Wickham, M. D. 

NlGHTLNGALE, FLORENCE. 

Paget, Sir James, Bart, 
Parkes, Edmund A.,.M. LL. 
Pavy,.E. W., M.D. 
Playfair, W^S., M.D. 
Simon,. John, C. B., D.CL. 
THOMESON,,Sir Henry. 
Waters, A. T.TL,, M. D.. 



Wells> T. Spencer,. 



" Not only is the work a Dictionary of Medicine 
in its fullest sense ; but it is so encyclopedic in its 
scope that it may be considered a condensed review 
of the entire field of practical medicine. Each sub- 
ject is marked up to date and contains in a nutshell 
the accumulated experience of the leading medical 
men of the day. As a volume for ready reference 
and careful study, it will be found of immense value 
to the general practitioner and student." — Medical 
Record. 

"The 'Medical Dictionary ' of Dr. Quain is 
something more than its title would at first indicate. 
It might with equal propriety be called an encyclo- 
paedia. The different diseases are fully discussed in 
alphabetical order. The description of each in- 
cludes an account of its various attributes, often 
covering several pages. Although we have pos- 
sessed the book only the short time since its publica- 
tion, its loss would leave a void we would not know 
how to fill." — Boston Medical and Surg. Journal. 

"Although a volume of over 1,800 pages, it is 
truly a multum in parvo, and will be found of 
much more practical utility than other works which 
might be named extending over many volumes. 
The profession of this country are under obligations 
to you for the republication of the work, and I de- 
sire to congratulate you on the excellence of the 
illustrations, together with the excellent typograph- 
ical execution in all respects." — Austin Flint, 
M. D. 

"It is with great pleasure, indeed, that we an- 
nounce the publication in this country, by the Ap— 
pletons, of this most superb work. Of all the 
medical works which have been, and which will be, 
published this year, the most conspicuous one as 
embodying learning and research — the compilation 
into one great volume, as it were, of the whole sci- 
ence and art of medicine — is the ' Dictionary of 
Medicine' of Dr. Quain. Ziemen's 'Practice of 
Medicine ' and Reynolds's ' System of Medicine ' 
are distinguished works, forming compilations, in 
the single department of practice, of the labors of 
many very eminent physicians, each one in his con- 
tributions presenting the results of his own observa- 
tions and experiences, as well as those of the inves- 
tigations of others. But in the dictionaiy of Dr. 
Quain there are embraced not merely the principles 
and practice of medicine in the contributions by the 
various writers of eminence, but general pathology, 
general therapeutics, hygiene, diseases of women 
and children, etc." — Cincinnati Medical News. 

" Criticism in detail we have not attempted, and 
this is in the main because there is not much room 



for it. Those who are most competent txnpass an 
opinion will, we. believe, admit that Dr. Quain has 
carried out a most arduous enterprise with great 
success. His 'Dictionary of Medicine' embodies 
an enormous amount of information in a.most ac- 
cessible form, and it deserves to take its place in the 
library of every medical man as a ready guide and 
safe counselor. Others, too, will find within its 
pages so much information of various kinds that it 
can not fail to establish itself as a standard work of 
reference." — St. James's Budget. 

' ' Therefore we helieve that as a^ whole the work 
wiiradmirably fulfill its purpose of being a standard 
book, of reference until, like other, dictionaries of 
progressive science, it wilLrequire to be remodeled 
or supplemented to keep pace with, advancing 
knowledge." — The Lancet {London). 

"I think ' Quain 's Dictionary of Medicine' an 
excellentwork, and of great practicaluse for every- 
day reference by the physician." — Alexander J. C 
Skene^.M. D., Professor of the Medical and Surg.~ 
cal Diseases of Wome?i, Long Island College Hos- 
pital, .Brooklyn, N. Y. 

" I regard ' Quain's Dictionary of" Medicine ' the 
most important, because most useful; publication of 
its kind issued from the medical press for many a 
year. In fact, I know of no similar work that can 
fitly be compared with it. The extraordinary facili- 
ties Dr. Quain possesses, in the choice of distin- 
guished collaborators, have been applied to the con- 
struction of a volume whose contents are so clear 
and compact, yet so full, that the hungriest seeker 
after the latest results of strictly medical research 
can be satisfied at one sitting." — Alexander 
Hutchins, M. D. 

" In this important work the editor has endeav- 
ored to combine tvvo^ features or purposes : in the 
first place, to offer a dictionary of the technical 
words used in medicine and the collateral sciences, 
and also to present a treatise on systematic medi- 
cine, in which the separate articles on diseases 
should be short monographs by eminent specialists 
in the several branches of medical and surgical sci- 
ence. Especially for the latter purpose, he secured 
the aid of such well-known gentlemen as Charles 
Murchison, John Rose Cormack, Tilbury Fox, 
Thomas Hayden, William Aitken, Charlton Bas- 
tian, Brown-Sequard, Sir William Jenner, Eras- 
mus Wilson, and a host of others. By their aid he 
may fairly be said to have attained his object of 
' bringing together the latest and most complete in- 
formation, in a form which would allow of ready 
and easy reference.' " — Med. and Surg. Reporter. 



36 D. APPLETON 6* CO.'S MEDICAL WORKS, 

A PRACTICAL TREATISE ON THE DISEASES OF 

CHILDREN. Third American from the eighth German edition. Revised 
and enlarged. Illustrated by Six Lithographic Plates. By Alfred 
Vogel, M. D., Professor of Clinical Medicine in the University of Dorpat, 
Russia. Translated and edited by H. Raphael, M. D., late House Sur- 
geon to Bellevue Hospital ; Physician to the Eastern Dispensary for the 
Diseases of Children, etc., etc. 

1 vol., 8vo, 640 pp. Cloth, $4.50 ; sheep, $5.50. 

"'Vogel's Treatise on Diseases of Children' derived from the possession of this work." — Buffalo 

has a world-wide reputation, having appeared in the Medical and Surgical Journal. 
Russian, German, Dutch, and English languages. 

1 his is a deserved success, for it is a book admira- " This is indeed a valuable addition to the litera- 
bly adapted to the wants both of the practitioner ture of Paediatrics. ... In this latest edition (3d 
and student. The present edition is brought well American) much has been added to the chapters on 
up to the present state of pathological knowledge, Artificial Nutrition, a subject of deep interest to the 
it is complete without prolixity, and the book btars practitioner, on Difficulties cf Dentition, and on 
upon its pages the evidence of the work of a skillful Nervous Diseases of Children. . . . This alone 
and experienced clinical practitioner. . . . We should be worth the price of the book, as the treat- 
would most heartily commend the book as one of ment of diseases of children is too much after the 
the most valuable upon the subject, and indeed few stereotyped fashion of the last century." — -DanieVs 
physicians can afford to forego the advanta^e^ to be Texas Medical Journal. 

THE NEW YORK MEDICAL JOURNAL: A Weekly 

Review of Medicine. Edited by Frank P. Foster, M D. 

The New York Medical Journal, now in the twenty-second year of its publication, is pub- 
lished every Saturday, each number containing twenty-eight large double-columned pages of 
reading matter. By reason of the condensed form in which the matter is arranged, it contains 
more reading matter than any other journal of its class in the United States. It is also more 
freely illustrated, and its illustrations are generally better executed, than is the case with other 
weekly journals. 

REASONS WHY PHYSICIANS SHOULD SUBSCRIBE FOR THE JOURNAL. 

BECAUSE: It is the LEADING JOURNAI of America, and contains more reading matter 
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BECAUSE: It is the exponent of the most advanced scientific medical thought. 
BECAUSE : Its contributors are among the most learned medical men of this country. 
BECAUSE: Its "Original Articles" are the results of scientific observation and research, and 
are of infinite practical value to the general practitioner. 

BECAUSE: The "Reports on the Progress of Medicine," which are published from time to 
time, contain the most recent discoveries in the various departments of medicine, and are 
written by practitioners especially qualified for the purpose. 

BECAUSE: The column devoted in each number to "Therapeutical Notes" contains a re'sume 
of the practical application of the most recent therapeutic novelties. 

BECAUSE: The Society Proceedings, of which each number contains one or more, are reports 

of the practical experience of prominent physicians who thus give to the profession the results 

of certain modes of treatment in given cases. 
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BECAUSE : Nothing is admitted to its columns that has not some bearing on medicine, or is not 

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D. APPLE TON & CO.'S MEDICAL WORKS. t>7 

PARALYSES: CEREBRAL, BULBAR, AND SPINAL. 

A Manual of Diagnosis for Students and Practitioners. By H. Charlton 

Bastian, M. A., M. D., F. R. S. ; Fellow of the Royal College of Physicians; 

Examiner in Medicine at the Royal College of Physicians ; Professor of 

Clinical Medicine and of Pathological Anatomy in University College, 

London, etc. 

With 136 Illustrations. Small 8vo, 671 pages. Cloth, $4.50. 

" The work is designed to facilitate diagnosis of " This is ' a manual of diagnosis for students 

the various forms of paralysis. . . . The book sup- and practitioners,' and as a special work on the di- 

plies a want long felt ; to come from this celebrated aenosis on localization of a paralyzing lesion we do 

author makes it much more valuable."— Buffalo not know of its equal in any language."— Virginia 

Medical and Surgical Journal. Medical Monthly. 

" We deem the work to be one of immense value „ We can stron ^i y re rommend Dr. Bastian's 

which must add greatly to its author's already large wQrk tQ thfi ctudent an d practitioner as a monument 

reputation, and we are heartily glad to see it repro- of learninff exceedingly well put together."— Lancet. 
duced by an American publishing house."— Medical 
Press 0/ Western New York. , , For dia ^ osis Bastian's work will take the high- 

" Throughout the work the author's mastery of est rank. It is remarkable for its philosophical tone 

the subject is constantly apparent, and it must take and for the author's critical comments on numerous 

rank as without a superior in its special department." obscure problems on neurology."— American Jour- 

—Medical and Surgical Reporter, nal of the Medical Sciences. 

ELEMENTS OF PRACTICAL MEDICINE. By Alfred 

H. Carter, M. D., Member of the Royal College of Physicians, London ; 
Physician to the Queen's Hospital, Birmingham, etc. 

Third edition, revised and enlarged. I vol., i2mo, 427 pages. Cloth, $3.00. 

"Although this work does not profess to be a wisely, perhaps, since we know so little about it ; 

complete treatise on the practice of medicine, it is and of that other almost unknown quantity in 

too full to be called a compend ; it is rather an in- medicine, scrofula, the author has with equal pru- 

troduction to the more exhaustive study embodied dence abstained from saying much. He admits 

in the larger text-books. An idea of the degree to such a condition as scrofulosis, but thinks it has no 

which condensation has been carried in it can be necessary connection with tuberculosis. He is a 

gathered from the statement that but twenty-one believer in the germ-theory of disease, and speaks 

pages are occupied with the diseases of the circula- of Koch's investigations and discoveries as very im- 

tory system. If the reader gets the impression that portant, to him almost conclusive, 
the physical signs are given somewhat too meager- "Notwithstanding the condensed make-up of 

ly, it is to be said that, by way of compensation, the book, it is quite comprehensive, including even 

the symptomatology in general is considered with cutaneous and venereal diseases. It contains much 

admirable perspicuity and good judgment. valuable information, and we may add that it is 

" Leucocythasmia is dismissed with one page — very readable." — New York Medical Journal. 

THE MINERAL SPRINGS OF THE UNITED STATES 

AND CANADA, with Analysis and Notes on the Prominent Spas of 

Europe and a List of Sea-side Resorts. An enlarged and revised edition 

By George E. Walton, M. D., Lecturer on Materia Medica in the Miami 

Medical College, Cincinnati. 

Second edition, revised and enlarged. I vol., i2mo, 414 pp. With Maps. $2. 

The author has given the analysis of all the springs in this country and those of the principal 
European spas, reduced to a uniform standard of one wine-pint, so that they may readily be com- 
pared. He has arranged the springs of America and Europe in seven distinct classes, and de- 
scribed the diseases to which mineral waters are adapted, with references to the class of waters 
applicable to the treatment ; and the peculiar characteristics of each spring as near as known are 
given — also the location, mode of access, and post-office address of every spring are mentioned. 
In addition, he has desc ibed the various kinds of baths and the appropriate use of them in the 
treatment of disease. 

" Precise and comprehensive, presenting not only use as intelligently and beneficially as they can other 
reliable analysis of the waters, but their therapeutic valuable alterative SLgents."~-Sanita?-ian. 
value, so that physicians can hereafter advise their 



38 



D. APPLETON &* CO.'S MEDICAL WORKS. 



DISEASES OF MEMORY : An Essay in the Positive Psy- 
chology. By Th. Ribot, Author of " Heredity," etc. Translated from the 
French by William Huntington Smith. 

i2mo. Cloth, $1.50. 



" Not merely to scientific, but to all thinking 
men, this volume will prove intensely interesting." 
— New York Observer. 

" M. Ribot has bestowed the most painstaking 
attention upon his theme, and numerous examples 
of the conditions considered greatly increase the 
value and interest of the volume." — Philadelphia 
North American. 

" 'Memory,' says M. Ribot, 'is a general func- 
tion of the nervous system. It is based upon the 
faculty possessed by the nervous elements of con- 
serving a received modification, and of forming as- 
sociations.' And again : ' Memory is a biological 
fact. A rich and extensive memory is not a collec- 
tion of impressions, but an accumulation of dynam- 



ical associations, very stable and very responsive to 
proper stimuli. . . . The brain is like a laboratory 
full of movement where thousands of operations are 
going on all at once. Unconscious cerebration, not 
being subject to restrictions of time, operating, so to 
speak, only in space, may act in several directions 
at the same moment. Consciousness is the narrow 
gate through which a very small part of all this 
work is able to reach us.' M. Ribot thus reduces 
diseases of memory to law, and his treatise is of ex- 
traordinary interest." — Philadelphia Press. 

" It is not too much to say that in no single work 
have so many curious cases been brought together 
and interpreted in a scientific manner." — Boston 
Evening Traveller. 



A TREATISE ON INSANITY, in its Medical Relations. 

By William A. Hammond, M. D., Surgeon-General U. S. Army (retired 
list) ; Professor of Diseases of the Mind and Nervous System, in the New 
York Post-Graduate Medical School ; President of the American Neuro- 
logical Association, etc. 

1 vol., 8vo, 767 pp. Cloth, $5; sheep, $6. 

In this work the author has not only considered the subject of Insanity, but has prefixed that 
division of his work with a general view of the mind and the several categories of mental faculties, 
and a full account of the various causes that exercise an influence over mental derangement, such 
as habit, age, sex, hereditary tendency, constitution, temperament, instinct, sleep, dreams, and 
many other factors. 

Insanity, it is believed, is in this volume brought before the reader in an original manner, and 
with a degree of thoroughness which can not but lead to important results in the study of psycho- 
logical medicine. Those forms which have only been incidentally alluded to or entirely disregard- 
ed in the text-books hitherto published are here shown to be of the greatest interest to the general 
practitioner and student of mental science, both from a normal and abnormal stand-point. To a 
great extent the work relates to those species of mental derangement which are not seen within 
asylum walls, and which, therefore, are of special importance to the non-asylum physician. 
Moreover, it points out the symptoms of Insanity in its first stages, during which there is most 
hope of successful medical treatment, and before the idea of an asylum has occurred to the patient's 
friends. 

commending the book to the medical profession, as 
it is to them it is specially addressed." — Therapeutic 
Gazette. 

" Dr. Hammond has added another great work 
to the long list of valuable publications which have 
placed him among the foremost neurologists and 
alienists of America ; and we predict for this volume 
the happy fortune of its predecessors — a rapid jour- 
ney through paying editions. We are sorry that our 
limits will not permit of an analysis of this work, 
the best text-book on insanity that has yet appeared." 
— The Polyclinic. 

" We are ready to welcome the present volume 
as the most lucid, comprehensive, and practical ex- 
position on insanity that has been issued in this 
country by an American alienist, and furthermore, 
it is the most instructive and assimilable that can be 
placed at present in the hands of the student unini- 
tiated in psychiatry. The instruction contained 
within its pages is a food thoroughly prepared for 
mental digestion : rich in the condiments that stimu- 
late the appetite for learning, and substantial in the 
more solid elements that enlarge and strengthen the 
intellect." — New Orleans Medical and Surgical 
Journal. 



" We believe we may fairly say that the volume 
is a sound and practical treatise on the subject with 
which it deals ; contains a great deal of information 
carefully selected and put together in a pleasant and 
readable form ; and, emanating, as it does, from an 
author whose previous works have met with a most 
favorable reception, will, we have little doubt, obtain 
a wide circulation." — The Dublin Journal of Medi- 
cal Science. 

"... The times are ripe for a new work on in- 
sanity, and Dr. Hammond's great work will serve 
hereafter to mark an era in the history of American 
psychiatry. It should be in the hands of every 
physician who wishes to have an understanding of 
the present status of this advancing science. Who 
begins to read it will need no urging to continue ; 
he will be carried along irresistibly. We unhesitat- 
ingly pronounce it one of the best works on insan- 
ity which has yet appeared in the English language." 
. — American Journal of the Medical Sciences. 

" Dr. Hammond is a bold and strong writer, has 
given much study to his subject, and expresses him- 
self so as to be understood by the reader, even if the 
latter does not coincide with him. We like the book 
very much, and consider it a valuable addition to the 
literature of insanity. We have no hesitancy in 



D. APPLE 7 ON &* CO:S MEDICAL WORKS. 39 

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" No scientific student can dispense with this J J 

monthly, and it is difficult to understand how any " A journal of eminent value to the cause of 

one making literary pretensions fails to become a popular education in this country." — New York 

regular reader of this journal. ' The Popular Sci- Tribune. 

ence Monthly ' meets a want of the medical profes- .. _, , ' . . , . , , . , ., , ... , 

sion not otherwise met. It keeps full pace with the . . Every physician's table should bear this yalu- 

progress of the times in all the departments of sci- able monthly, which we believe to be one of the 

entific pursuit."- Virginia Medical Monthly. most m ^f^ a " d ^™**e ° f J he Periodicals 

a J now published, and one which is destined to play a 

" Outside of medical journals, there is no peri- large part in the mental development of the laity of 

odical published in America as well worthy of being this country." — Canadian Journal of Medical Sci- 

placed upon the physician's library-table and regu- ence. 

larly read by him as " The Popular Science Month- ,. ,_,. . . ,, ., . , . . ... 

Iv. ' -St. Luis Clinical Record. . This magazine is worth its weight in gold, for 



ly.'" — St. Louis Clinical Record. 



its service in educating the people." — American 



" ' The Popular Science Monthly ' is invaluable Journal of Education (St. Louis). 

DISEASES OF THE OVARIES: Their Diagnosis and 

Treatment. By T. Spencer Wells, Fellow and Member of Council of 

the Royal College of Surgeons of England, etc., etc. 

1 vol., 8vo, 478 pp. Illustrated. Cloth, $4.50. 

In 1865 the author issued a volume containing reports of one hundred and fourteen cases of 
Ovariotomy, which was little more than a simple record of facts. The book was soon'Out of print, 
and, though repeatedly asked for a new edition, the author was unable to do more than prepare 
papers for the Royal Medical and Chirurgical Society, as series after series of a hundred cases ac- 
cumulated. On the completion of five hundred cases, he embodied the results in the present vol- 
ume, an entirely new work, for the student and practitioner, and trusts it may prove acceptable to 
them and useful to suffering women. 



4Q 



D. APPLETON &> CO.'S MEDICAL WORKS. 



LECTURES ON THE PRINCIPLES OF SURGERY. 

Delivered at the Bellevue Hospital Medical College. By the late W. H. 
Van Buren, M. D., LL. D. Edited by Dr. Lewis A. Stimson. 

I vol., 8vo, 588 pages. Cloth, $4.00 ; sheep, $5.00. 



" The name of the author is enough. The book 
will sell. The lectures are good." — Denver Medi- 
cal Times. 

"If we are to judge of the interesting style by 
the mere reading of these lectures, how greatly they 
must have been appreciated by those who heard 
them by the teacher ! There is nothing dry or prosy 
in them. The illustrations of principles are drawn 
from the clinical material of the teacher, and are 
always fresh and a propos. Past and present theo- 
ries are compared in such a way as to give the stu- 
dent an interest in the work of older pathologists, 
and to point out progress made, without wearying 



him with a dry narration at a time when he is not 
able to comprehend the underlying philosophy. 

"Dr. Van Buren's popularity as a teacher can 
be easily understood from a study of this volume. 
His manner is vivacious, his matter select, and his 
fullness of knowledge easily discernible. He writes 
like one in authority, full of enthusiasm, and pos- 
sessed of the skill of imparting to students just that 
sort of knowledge best suited to their future intel- 
lectual growth. 

"The work is handsomely printed, with full- 
faced, clear type and leaded lines, and is in every 
way a credit to the publishers." — North Carolina 
Medical Journal. 



OSTEOTOMY AND OSTEOCLASIS, for the Correction of 

Deformities of the Lower Limbs. By Charles T. Poore, M. D., Surgeon 
to St. Mary's Free Hospital for Children, New York. 

1 vol., 8vo, 202 pages, with 50 Illustrations. Cloth, $2.50. 





" This handsome and carefully-prepared mono- 
graph treats of osteotomy as applied to the repair 
of genu valgum, genu varum, anchylosis of the 
knee-joint, deformities of the hip-joint, and for 
curves of the tibia. The author has enjoyed large 
opportunities to study these special malformations 
in the hospitals to which he is attached, and de- 
scribes the operations from an ample observation. 
Quite a number of well-engraved illustrations add 
to the value of the volume, and an exhaustive bib- 
liography appended enables the reader to pursue 
any topic in which he may be interested into the 
productions of other writers." — Medical and Sur- 
gical Reporter. 

" Dr. Poore, who has already become so well 
known by journal articles on bone surgery, has con- 



densed his experience in the work before us. He 
has succeeded in doing this in a very satisfactory 
way. We can not too strongly commend the clear 
and succinct manner in which the author weighs 
the indications for treatment in particular cases. 
In so doing he shows a knowledge of his subject 
which is as extensive as it is profound, and no one 
at all interested in orthopedy can read his conclu- 
sions without profit. His own cases, which are 
carefully reported, are valuable additions to the lit- 
erature of the subject. These, together with oth- 
ers, which are only summarized, contain so much 
practical information and sound surgery that they 
give a special value to the work, altogether inde- 
pendent of its other excellences. It is a good book 
in every way, and we congratulate the author ac- 
cordingly." — Medical Record. 



D. APPLETON 6- CO.'S MEDICAL WORKS. 



41 



A TREATISE ON BRAIN-EXHAUSTION, with some 

Preliminary Considerations on Cerebral Dynamics. By J. Leonard Corn- 
ing, M. D., formerly Resident Assistant Physician to the Hudson River 
State Hospital for the Insane ; Member of the Medical Society of the 
County of New York, of the Physicians' Mutual Aid Association, of the 
New York Neurological Society, of the New York Medico-Legal Society, 
of the Society of Medical Jurisprudence ; Physician to the New York Neu- 
rological Infirmary, etc. ; Member of the New York Academy of Medicine. 

Crown 8vo. Cloth, $2.00. 



" Dr. Coming's neat little volume has the merit 
of being highly suggestive, and, besides, is better 
adapted to popular reading than any other profes- 
sional work on the subject that we know of." — Pa- 
cific Medical and Surgical Journal. 

"This is a capital little work on the subject 
upon which it treats, and the author has presented, 
from as real a scientific stand-point as possible, a 
group of symptoms, the importance of which is 
sufficiently evident. To fully comprehend the ideas 
as presented by the author, the whole book should 
be read ; and, as it consists of only 234 pages, the 
task would not be a severe or tedious one, and the 
information or knowledge obtained would be much 
more than equivalent for the time spent and cost 
of book included. Literary men and women would 
do well to procure it." — Therapeutic Gazette. 



" This book belongs to a class that is more and 
more demanded by the cultured intelligence of the 
period in which we live. Dr. Corning may be 
ranked with Hammond, Beard, Mitchell, and 
Crothers, of this country, and with Winslow, An- 
stie, Thompson, and more recent authors of Great 
Biitain, in discussing the problems of mental dis- 
tuibance, in a style that makes it not only profit- 
able but attractive reading for the student of psy- 
chology. The author has divided the work into 
short chapters, under general headings, which are 
again subdivided into topics, that are paragraphed 
in a concise and definite form, which at once strikes 
the careful reader as characteristic of a method that 
is terse, concise, and readily apprehended. There 
are twenty-eight of these pithy chapters, which no 
student of mental diseases can fail to read without 
loss." — American Psychological Journal. 



PRACTICAL MANUAL OF DISEASES OF WOMEN 

AND UTERINE THERAPEUTICS. For Students and Practitioners. 
By H. Macnaughton Jones, M. D., F. R. C. S. I. and E., Examiner in 
Obstetrics, Royal University of Ireland ; Fellow of the Academy of Medi- 
cine in Ireland ; and of the Obstetrical Society of London, etc. 

1 vol., i2mo. 410 pages. 188 Illustrations. Cloth, $3 co. 



"As a concise, well- written, useful manual, we 
consider this one of the best we have ever seen. 
The author, in the preface, tells us that ' this book 
is simply intended as a practitioner's and student's 
manual. I have endeavored to make it as practical 
in its teachings as possible.' The style is pleasant 
to peruse. The author expresses his ideas in a clear 
manner, and it is well up with the approved meth- 
ods and treatment of the day. It is well illustrated, 
and due credit is given to American gynaecologists 
for work done. It is a good book, well printed in 
good, large type, and well bound." — New E7igland 
Medical Mo7tthly. 

" It is seldom that we see a book so completely 
fill its avowed mission as does the one before us. 
It is practical from beginning to end, and can not 
fail to be appreciated by the readers for whom it is 
intended. The author's style is terse and perspicu- 
ous, and he has the enviable faculty of giving the 
learner a clear insight of his methods and reasons 
for treatment. Prepared for the practitioner, this 
little work deals only with his every-day wants in 
ordinary family practice. Every one is compelled 
to treat uterine disease who does any general busi- 
ness whatever, and should become acquainted with 
the minor operations thereto pertaining. The book 



before us covers this ground completely, and we 
have nothing to offer in the way of criticism." — 
Medical Record. 

" The manual before us is not the work of a spe- 
cialist — using this term in a narrow sense — but of 
an author already favorably known to the students 
of current medical literature by various and com- 
prehensive works upon other branches of his profes- 
sion. Nor is it, on the other hand, the work of an 
amateur or merely ingenious collab. rateur, for Dr. 
Macnaughton Jones's gynaecological experience in 
connection with the Cork Hospital for Women and 
the Cork Maternity was such as fairly entitles him 
to speak authoritatively upon the subjects with 
which it deals. But, after so many works by avowed 
specialists, we are glad to welcome one upon Gynae- 
cology by an author whose opportunities and energy 
have enabled him to master the details of so many 
branches of medicine. We are glad also to be able 
to state that his work compares very favorably with 
others of the same kind, and that it does admirably 
fulfill the purposes with which it was written — ' as 
a safe guide in practice to the practitioner, and an 
assistance in the study of this branch of his profes- 
sion to the student.'" — Dublin Journal of Medical 
Science. 



42 



D. APPLE TON 6- CO.'S MEDICAL WORKS. 



A HAND-BOOK OF THE DISEASES OF THE EYE, 

AND THEIR TREATMENT. By Henry R. Swanzy, A. M., M. B., 
F. R. C. S. L, Surgeon to the National Eye and Ear Infirmary ; Ophthalmic 
Surgeon to the Adelaide Hospital, Dublin. 

Crown 8vo, 437 pages. With 122 Illustrations, and Holmgren's Tests for Color-Blindness. 

Cloth, $3.00. 

" Though, amid the numerous recent text-books 
on eye-diseases, there would appear to be little 
room or necessity for another, we must admit that 
this one justifies its presence, by its admirable type, 
illustrations, and dress, by its clear wording, and, 
above all, by the vast amount of varied matter 
which it embraces within the relatively small com- 
pass of some four hundred pages. The author has 
omitted — and, in our opinion, with perfect wis- 
dom — the usual collection of indifferent, second- 
hand ophthalmoscopic plates. So, also, he has not 
included test-types, though he has appended, for 
explanatory purposes, the fan which is often used 
in astigmatism. Admirable samples of the colored 
wools, used in Holmgren's tests, are sewn into the 
cover, and, by aid of thase, it will be perfectly within 



the power of any one, wherever residing, to make a 
proper collection of colored wools and tests for the 
qualitative estimation of congenital color-defects. 
We have criticised the book at length, and drawn at- 
tention freely to points on which the author's opin- 
ion is at variance with the commonly received teach- 
ing. This we have done because there is much 
individuality in the work, which bears every mark 
of having been well thought out and independently 
written. In these lespects it presents a marked su- 
periority over the ordinary run of medical hand- 
books ; and we have no hesitation in recommending 
it to students and young piactitioners as one of the 
very best, if not actually the best, work to procuie 
on the subject of ophthalmology." — British Medi- 
cal Journal. 



DISEASES OF THE HEART AND THORACIC AOR- 
TA. By Byrom Bramwell, M. D., F. R. C. P. E., Lecturer on the Prin- 
ciples and Practice of Medicine and on Medical Diagnosis in the Extra- 
Academical School of Medicine, Edinburgh ; Pathologist to the Royal 
Infirmary, Edinburgh, etc. 

Illustrated with 226 Wood Engravings and 68 Lithograph Plates, showing 91 Figures — in all, 
317 Illustrations. 1 vol., 8vo, 783 pages. Cloth, $8.00 ; sheep, $9.00. 

" A careful perusal of this work will well repay 
the student and refresh the memory of the busy 
practitioner. It is the outcome of sound knowledge 
and solid work, and thus devoid of all ' padding,' 
which forms the bulk of many monographs on this 
and other subjects. The material is treated with 
due regard to its proportionate importance, and the 
author has well and wisely carried out his apparent 
intention of rather furnishing a groundwork of 
knowledge on which the reader must build for him- 
self by personal observation, than of making excur- 
sions into the region of dogma and of fancy by 
which his book might have secured a perhaps more 
rapid but certainly a more evanescent success than 
that which it will now undoubtedly and deservedly 
attain." — Medical Times and Gazette. 

"In this elegant and profusely illustrated vol- 
ume Dr. Bramwell has entered a field which has 
hitherto been so worthily occupied by British au- 
thors — Hope, Hayden, Walshe, and others ; and 



we can not but admire the industry and care which 
he has bestowed upon the work. As it stands, it 
may fairly be taken as representing the stand-point 
at which we have arrived in cardiac physiology and 
pathology ; for the book opens with an extended 
account of physiological facts, and especially the 
advances made of late years in the neuro-muscular 
mechanism of the heart and blood-vessels. Al- 
though in this respect physiological research has 
outstripped clinical and pathological observation, 
Dr. Bramwell has, we think, done wisely in so in- 
troducing his treatise, and has thereby greatly add- 
ed to its value. A chapter upon thoracic aneurism 
terminates a work which, from the scientific man- 
ner in which the subject is treated, from the care 
and discrimination exhibited, and the copious elab- 
orate illustrations with which it is adorned, is one 
which will advance the author's reputation as a 
most industrious and painstaking clinical observer." 
— Lancet. 



PHYSIOLOGY, 

Sanitary Inspector of 



THE ESSENTIALS OF ANATOMY, 
AND HYGIENE. By Roger S. Tracy, M. D., 
the New York City Health Department. 

i2mo. Cloth, $1.25. 

This work has been prepared in response to the demand for a thoroughly scientific and yet 
practical text-book for schools and academies, which shall afford an accurate knowledge of the 
essential facts of Anatomy and Physiology, as furnishing a scientific basis for the study of 
Hygiene and the Laws of Health. It also treats, in a rational manner, of the physiological effects 
of alcohol and other narcotics, fulfilling all the requirements of recent legislative enactments \ipon 
this subject. 



D. APPLETON 6- CO:S MEDICAL WORKS. 



43 



THE RELATION OF ANIMAL DISEASES TO THE 

PUBLIC HEALTH, and their Prevention : With a Brief Historical 
Sketch of the Development of Veterinary Medicine, from the Earliest Ages 
to the Present Time ; and a Critical Historical Sketch of the Leading 
Schools of the World, showing the Reasons which led to their Foundation, 
and with the Endeavor to draw from their Experiences Teachings of Value 
toward the Establishment of a General Veterinary Police-hygienic System 
and Veterinary Schools in this Country. By Frank S. Billings, Veteri- 
nary Surgeon, Graduate of the Royal Veterinary Institute, Berlin ; Mem- 
ber of the Royal Veterinary Association of the Province of Brandenburg, 
Prussia ; Honorary Member of the Veterinary Society of Montreal, Can- 
ada, etc., etc. 

i vol., 8vo. Cloth, $4.00. 

"This is the great health-book of Dr. Frank S. least should be in the libraries of every national, 
Billings, and it is not too much to promise that a State, city, town, and county Board of Health. It 
study and observance of its teachings, that are the certainly should be studied by every teacher and 
results of actual experiments, will work a revolution scientific practitioner of veterinary medicine, and 
in the sanitary condition of the United States. . . . will be of great sendee to every great stock and cat- 
It is a work for all stock-breeders and for all fami- tie holder and dealer. ... It is evidently written 
lies." — Louisville Courier- Journal, by a man of great ability and high culture, well 

,, T ,. . ., -..., c , ■ . . ., versed both in the literature and science as well as 

'This is the title of a work jus given to the h . j b rf f fafe bj guch 

wor d and in its pages subjects of vital interest are has P t and ina g erable right to have opinions 

treated of in a lucid and perspicuous manner. ... „*!,;*„,„. ~,-a i,^ u^c t-u~™ „„a a^^ c ™* w-^*.^ 

~,, ,, . , ,• u j l * j. v. u iU 01 his own : and he has them, and does not hesitate 

These well-established statements should arouse the . „ Mo \i* am w „ -u „ „„a u i:» ~ a,..* 

,,.,,. . -, ., . 1 1 r . ,.. to express tnem. . . . We hope and believe that 

pubic feeling: to provide that boards of health ., p , ... , • j u n * i, 

',,, & , , * , rr- ■ . ■ .-. ■ c the volume will be received by all, except perhaps 

should be careful and efficient in the exercise of , ., • ,, . . , , .{, ./ * 1 

f. . , .. , ., . • j. •, , by those especially attacked, with the great welcome 

their duties, as also that, as individuals, every one ,./.•. Ku a -ui- u * * t 

, ij 1 u * * 1 a ru- \c u- e that its author and publishers must expect for it. 

should labor to take good care of himself, his f am- ft m take { d P d f h P j 

ily, and his domestic animals. -New York Times. ^ of Hmiard and Ro f ertson> and g/^ purdy 

" This handsome volume does great credit to its scientific matters will lead them. Either of these 
author and publishers. It is an excellent book in works, together with Dr. Billings's, will make al- 
most respects, an extraordinary one in many, and most a complete library on veterinary medicine." — 
an objectionable one in very few. It at the very yournal 0/ Comparative Medicine and Surgery. 



PYURIA; or, PUS IN THE URINE, AND ITS TREAT- 

MENT : Comprising the Diagnosis and Treatment of Acute and Chronic 
Urethritis, Prostatitis, Cystitis, and Pyelitis, with especial reference to their 
Local Treatment. By Dr. Robert Ultzmann, Professor of Genito-Uri- 
nary Diseases in the Vienna Poliklinik. Translated, by permission, by Dr. 
Walter B. Platt, F. R. C S. (Eng.), Baltimore. 

i2mo. Cloth, $1.00. 

" Those of the profession who are familiar with but also for the many practical suggestions regard- 

the works of Professor Ultzmann will welcome this ing treatment to be found in the chapter on Thera- 

translation as constituting a real addition to our lit- peutics. The translator is to be congratulated upen 

erature on genito-unnary diseases. It can not be the excellent manner in which his work has been 

too highly recommended to the attention of the pro- accomplished. The book is neatly and tastefully got 

fession, not only on account of its scientific value, up by the publishers." — Maryland Med. Journal. 

HAND-BOOK OF SANITARY INFORMATION FOR 

HOUSEHOLDERS. Containing Facts and Suggestions about Ventila- 
tion, Drainage, Care of Contagious Diseases, Disinfection, Food, and 
Water. With Appendices on Disinfectants and Plumbers' Materials. By 
Roger S. Tracy, M. D., Sanitary Inspector of the New York City Health 

Department. 

i6mo. Cloth, 50 cents. 



44 



D. APPLE TON &> CO.'S MEDICAL WORKS. 



A TREATISE ON NERVOUS DISEASES: Their Symp- 
toms and Treatment. A Text-book for Students and Practitioners. By S. 
G. Webber, M. D., Clinical Instructor in Nervous Diseases, Harvard Med- 
ical School ; Visiting Physician for Diseases of the Nervous System at the 
Boston City Hospital, etc. 

I vol., 3vo, 415 pp. 15 Illustrations. Cloth, $3.00. 



" The book before us is especially adapted to the 
needs of the general practitioner who, though con- 
scious of his inability to discern and trace the nerv- 
ous element in the cases under his care, realizes 
very fully that this inability is not consonant with 
the best interests of his patient. Dr. Webber has 
■not written for the specialist, but for the student 
and general practitioner, who will find in his book 
what they most need for the diagnosis and treat- 
ment of the diseases as they present themselves in 
general practice. His style is very readable and 
lucid, and is well adapted to those who have not 
specially prepared themselves to understand the 



peculiar language of the more advanced neurologist. 
He covers very completely the field of nervous affec- 
tions, and his book will prove a very valuable acqui- 
sition to the library of the intelligent physician." — 
Medical Age. 

" The beauty and usefulness of the book are much 
enhanced by the fact that it is not loaded down with 
references to other authors, but proceeds in an orig- 
inal manner to sum up all that is known to the 
present day upon the subjects treated. Taking the 
book as a whole it is one of the best we have seen 
in many a day." — Texas Courier-Record. 



THE CURABILITY AND TREATMENT OF PUL- 
MONARY PHTHISIS. By S. Jaccoud, Professor of Medical Pathology 
to the Faculty of Paris ; Member of the Academy of Medicine ; Physician 
to the Lariboisiere Hospital, Paris, etc. Translated and edited by Montagu 
Lubbock, M. D. (London and Paris), M. R. C. P. (England), etc. 
8vo, 407 pp. Cloth, $4.00. 



" This is the work of that most eminent French- 
man of the Ecole de Midecine of Paris, and the 
translation of Lubbcck is strong and masterly inas- 
much as it evidences the possession of a large 
vocabulary knowledge of both the original and 
English. No man of the present day, with the 
single exception perhaps of Hughes Bennet, has 
devoted as much careful study to the climatic treat- 
ment of phthisis as Dr. Jaccoud, and his conclusions 
on this point so far as regards the Continent of 
Europe must be deemed final." — Cincinnati Lancet 
and Clinic. 



" M. Jaccoud, the author of the work, and the 
eminent professor of the Ecole de Midecine, Paris, 
is generally recognized on the Continent as one of 
the best authorities on pulmonary phthisis, so that 
an English edition of his work will certainly be 
very acceptable to those interested in the subject. 
. . . M. Jaccoud' s reputation is justly so great that 
his opinions with respect to the treatment will be 
read with general interest." — Texas Courier-Record 
of Medicine. 



THE USE OF THE MICROSCOPE IN CLINICAL 

AND PATHOLOGICAL EXAMINATIONS. By Dr. Carl Friedlaen- 
der, Privat-Docent in Pathological Anatomy in Berlin. Translated from 
the enlarged and improved second edition, by Henry C. Coe, M. D., etc. 
With a Chromo-Lithographt i2mo, 195 pp., with copious Index. Cloth, $1.00. 



" We are very much pleased to see Dr. Fried- 
laender's little book make its appearance in English 
dress. As we have a practical acquaintance of the 
German edition since its appearance, we can speak 
of it in terms of unqualified praise. . . . Every one 
doing pathological work should have this little book 
in his possession. . . . The translator has done his 
work well, and has certainly conferred a great favor 
on all microscopists by placing within the reach of 
every one the work of so accomplished a teacher as 
Dr. Carl Fried laender." — Canada Medical and Sur- 
gical Journal. 



" Much good has been done in placing this little 
work in the hands of the profession. The technique 
of preparing, cutting, and staining specimens is 
given at some length ; also rules for the examination 
of the various bodily fluids in both health and 
disease. The use of the microscope with high pow- 
ers, immersion lenses, and other accessories, is ex- 
plained very clearly. It is a very readable volume, 
even for those not engaged in actual laboratory 
work. A chromo-lithograph shows the various 
forms of disease-germs which have been definitely 
isolated." — Medical Record. 



MEDICAL ETHICS AND ETIQUETTE. Commentaries 

on the National Code of Ethics. By Austin Flint, M. D. 
i2mo, 101 pp. 60 cents. 



D. APPLE TON & CO.'S MEDICAL WORKS. 



45 



A MANUAL OF DERMATOLOGY. By A R. Robinson, 

M. B., L. R. C. P. and S. (Edinburgh), Professor of Dermatology at the 
New York Polyclinic ; Professor of Histology and Pathological Anatomy at 
the Woman's Medical College of the New York Infirmary. Revised and 
corrected. 

8vo, 647 pp. Cloth, $5.00. 



" It includes so much good, original work, and 
so well illustrates the best practical teachings of the 
subject by our most advanced men, that I regard it 
as commanding at once a place in the very front 
rank of all authorities. . . . " — James Nevins 
Hyde, M. D. 

" Dr. Robinson's experience has amply qualified 
him for the task which he assumed, and he has given 
us a book which commends itself to the considera- 
tion of the general practitioner." — Medical Age. 



' ' In general appearance it is similar to Duhring's 
excellent book, more valuable, however, in that it 
contains much later views, and also on account of 
the excellence of the anatomical description accom- 
panying the microscopical appearances of the diseases 
spoken of." — St. Louis Med. and Surg. Journal. 

' ' Altogether it is an excellent work, helpful to 
every one who consults its pages for aid in the study 
of skin-diseases. No physican who studies it will 
regret the placing of it in his library." — Detroit 
Lancet. 



AN ATLAS OF CLINICAL MICROSCOPY. By Alex- 
ander Peyer, M. D. Translated and edited by Alfred C. Girard, M. D., 

Assistant Surgeon United States Army. First American, from the manu- 
script of the second German edition, with Additions. 
90 Plates, with 105 Illustrations, Chromo-Lithographs. Square 8vo. Cloth, $6.00. 



"All who are interested in clinical microscopy 
will be pleased with the design and execution of this 
work, and will feel under obligation to the author, 
translator, and publishers for placing so valuable a 
work in their hands. The plates in which are figured 
the various urinary inorganic deposits are especially 
fine, and the various forms of tube-casts, hyaline, 
waxy, epithelial, and mucous, are depicted with great 
fidelity and accuracy." — Philadelphia Med. Times. 

" To those students and practitioners of medicine 
who are interested in microscopical work and who 



are familiar with the use of this valuable aid to hu- 
man vision in the study of nature, the present work 
will prove of incalculable value, since it represents 
the original work of an accomplished microscopist 
and artist. Accompanying the plates is a text of 
explanatory notes showing the various methods of 
working with the microscope and the significance of 
what is observed. The plates have been most 
handsomely printed. We have seen nothing in this 
special line of study that will compare in point of 
accuracy of detail and artistic effect with the work 
under consideration." — Maryland Med. Journal. 



ELEMENTS OF MODERN MEDICINE, including Princi- 

pies of Pathology and Therapeutics, with many Useful Memoranda and 
Valuable Tables of Reference. Accompanied by Pocket Fever Charts. 
Designed for the Use of Students and Practitioners of Medicine. By R. 
French Stone, M. D., Professor of Materia Medica and Therapeutics and 
Clinical Medicine in the Central College of Physicians and Surgeons, 
Indianapolis ; Physician to the Indiana Institute for the Blind ; Consulting 
Physician to the Indianapolis City Hospital, etc., etc. 
In wallet-book form, with pockets on each cover for Memoranda, Temperature Charts, etc., $2.50. 



" This is an abridged work in pocket-book form, 
presenting the more advanced views of leading 
authorities, with reference to general pathologv and 
therapeutics. Under general pathology are included 
articles on the origin, nature, and duration of dis- 
ease, chief symptoms, diagnosis, prognosis, and 
treatment. In the second part will be found what is 
regarded by the author as an improved classification 
of drugs, followed by articles on their physiological 
action, indications, and methods of use. The work 
contains a fund of useful information culled from 
the best authorities in the Old and New World." — 
Canada Lancet. 



" This is a neatly printed pocket manual of medi- 
cal practice. It is a well-condensed compilation of 
the kind, containing a short sketch of nearly every- 
thing that is met with in practice. The fever charts 
are well arranged, and there is a convenient thera- 
peutic table which will be found valuable. It will 
probably be more suitable for young practitioners, 
on account of its containing many practical points 
that are not to be found elsewhere in such a con- 
densed manner. It will be found a valuable aid to 
those just commencing practice." — Medical Herald. 



4 6 



D. APPLETON &- CO:S MEDICAL WORKS. 



A TEXT-BOOK OF OPHTHALMOSCOPY. By Edward 

G. Loring, M. D. Part I. — The Normal Eye, Determination of Refrac- 
tion, and Diseases of the Media. 

Specimen of Illustration. 



8vo. 267 pp., with 131 
Illustrations, and Four 
Chromo -Lithograph Plates ( 
containing 14 Figures. 
Cloth, $5.00. 



" The ' Text-book of Oph- 
thalmoscopy,' by Edward G. 
Loring, M. D., is a splendid 
work. ... I am well pleased 
with it, and am satisfied that 
it will be of service both to 
the teacher and pupil. . . . 
In this book Dr. Loring has 
given us a substantial exposi- 
tion of Nature's deeds and 
misdeeds as they are found 
written in the eye, and the 
key by means of which they 
can be comprehended." — W. 
R. Amick, A M., M. D., Pro- 
fessor of Ophthalmology and 
Otology, Cincinnati College 
of Medicine and Surgery. 



THE DISEASES OF SEDENTARY AND ADVANCED 

LIFE. A Work for Medical and Lay Readers. By J. Milner Foth- 

ergill, M. D., M. R. C. P., Physician to the City of London Hospital for 

Diseases of the Chest (Victoria Park) ; late Assistant Physician to the West 

London Hospital ; Hon. M. D., Rush Medical College, Chicago ; Foreign 

Associate Fellow of the Royal College of Physicians of Philadelphia. 

Small 8vo, 296 pp. Cloth, $2.00. 

"This work is written to fill a gap in medical forgotten. . . . The writer ventures to think that in 

literature. The diseases of sedentary and advanced this work an aspect of disease is presented which is 

life lie a little outside and beyond the ordinary text- not always kept sufficiently in view ; and which will 

books of practice of physic. As such a work is cer- make the work acceptable even to some well-read 

tain to be read by lay-readers, the fact has not been members of the profession." — From the Preface. 

THE DIAGNOSIS AND TREATMENT OF DISEASES 

OF THE EAR. By Oren D. Pomeroy, M. D., Surgeon to the Manhat- 
tan Eye and Ear Hospital, etc. With One Hundred Illustrations. New 
edition, revised and enlarged. 

8vo. Cloth, $3.00. 




1 ' The several forms of aural disease are dealt 
with in a manner exceedingly satisfactory. The 
work is quite exhaustive in its scope, and will repre- 
sent an authority on this subject which we believe 
will be duly appreciated by the profession." — Medi- 
cal Record. 

"The author uses good language, telling in a 
clear and interesting manner what- he has to say. 
The book is a valuable one for both students and 
practitioners." — Lancet and Clinic. 



" The author's opportunity to know of what he 
writes has been abundant, and the work itself shows 
that he has made good use of his information. We 
have not the slightest reason for not commending it 
not only to the otologist but also to the general 
student. " — Therapeutic Gazette. 

" Well arranged and well written, and not too 
scientific." — Boston Medical and Surgical Jour- 
nal. 



D. APPLETON &> CO:S MEDICAL WORKS. 



47 



LOCAL ANESTHESIA IN GENERAL MEDICINE 

AND SURGERY. Being the Practical Application of the Author's Re- 
cent Discoveries in Local Anaesthesia. By J. Leonard Corning, M. D., 
author of "Brain Exhaustion," "Carotid Compression," "Brain Rest," etc. ; 
Fellow ol the New York Academy of Medicine, Member of the Medical 
Society of the County of New York, of the New York Neurological 
Society, etc. 

Small 8vo, 103 pp. With 14 Illustrations. Cloth, $1.25. 

" The work has in it much that is instructive and 
attractive, and is quite an addition to a field of lit- 
erature which may be considered novel. . . ." — 
College and Clinical Record, 



" The book should find its way everywhere on its 
merits, and will be welcomed by a host of interested 
readers." — Medical Press of Western New York. 

" This is a valuable little work on cocaine, giving 
the author's method of increasing and prolonging 
the cocaine anaesthesia. . . . Some very formidable 
operations, even amputation of the thigh, have been 
performed by this method and with but very little 
pain. It is a valuable contribution to surgical prac- 
tice." — Peoria Medical Monthly. 

"The book merits careful consideration, as being 
an interesting and practical original contribution to 
surgery." — Medical Bulletin. 

" The work is worthy the careful study of every 
practical surgeon and physician. It is clearly writ- 



ten, with little useless padding. The author stops 
when he has said what he wishes." — American 
Lancet. 

4 ' To Dr. Corning belongs the honor of discov- 
ering that cocaine anaesthesia may be almost indefi- 
nitely prolonged by checking the circulation in the 
part anaesthetized by means of an Esmarch's band- 
age, and any one desiring full details should send to 
the Appletons for this neat little work." — Kansas 
City Medical Index. 

"It is of interest to note the author's statement 
that the ' discovery in question was in no respect the 
result of a chance, but was, on the contrary, the di- 
rect outgrowth of a chain of deductive reasoning.' 
The importance of this discovery needs no insisting 
on ; and no surgeon can afford to be in ignorance 
of its details, or can fail to be scientifically the richer 
for the possession of the present work." — New Eng- 
land Medical Gazette. 



A TEXT-BOOK OF NURSING. For the Use of Training- 

Schools, Families, and Private Students. Compiled by Clara S. Weeks? 

Graduate of the New York Hospital Training- School ; Superintendent of 

Training-School for Nurses, Paterson, New Jersey. 

l2mo, 396 pp., with 13 Illustrations, Questions for Review and Examination, and Vocabulary of 

Medical Terms. $1.75. 



"This book, in twenty-three chapters, communi- 
cates a large quantity of useful information in a 
form intelligible to the public. It is well written, 
remarkablv correct, sufficiently illustrated, and hand- 
somelv printed. The amount of technical skill and 
knowledge required of nurses at the present day 
makes the use of some text-book indispensable. 
To those who need such a work we can speak ap- 



provingly of its design, scope, and execution." — 
Philadelphia Medical Times. 

" This is an admirably written book, and is full 
of those important practical details necessary for 
the medical and surgical nurse. In fact, it could be 
read with profit by every medical student and young 
practitioner." — Medical Record. 



MEDICINE OF THE FUTURE. An Address prepared for 

the Annual Meeting of the British Medical Association in 1886. By Aus- 
tin Flint (Senior), M. D., LL. D. 

With Steel Engraving of the author. i2mo, 37 pages. Cloth, $1.00. 



"The late Dr. Austin Flint was apoointed *~> 
read the address on Medicine before the British 
Medical Association at its meeting in 1886. The 
manuscript was found among his papers, and the 
address is printed preciselv as it was written. The 
proof was reverently read by his son, who dedicates 
this, his father's last literary work, to the profession 
he so loved and admired. The book contains an 
excellent portrait of the late Dr. Flint. It is a most 
fitting: memorial volume. The address itself is a 
most scholarly work, and should be added to the 
library of every practitioner." — Buffalo Medical and 
Surgical Journal. 



" The above, the last of the thoughts of Austin 
Flint, should be in the bands of every admirer of 
the ereat and ecod physician, and who that knows 
anything of American medicine did not admire 
him ? Flint never wrote anything that was not 
p-ood, and the nice little book— souvenir— before us 
bears that characteristic. The manuscript was found 
among his papers after his death, and was printed 
just as it was written. It contains a good likeness 
of the author— an elegant steel engraving— and 
nothing has been left undone by the well-known 
publishers to make it attractive." — Mississippi Val- 
ley Medical Monthly. 



4 8 



Z>. APPLE TON & CO.'S MEDICAL WORKS, 



A TEXT-BOOK OF MEDICINE. For Students and Prac- 
titioners. By Adolph Strumpell, formerly Professor and Director of the 
Medical Polyclinic at the University of Leipsic. Translated, by permission, 
from the second and third German editions by Herman F. Vickery, A. B., 
M. D., Assistant in Clinical Medicine, Harvard Medical School, etc., and 
Philip Coombs Knapp, Physician to Out-patients with Diseases of the 
Nervous System, Boston City Hospital, etc. With Editorial Notes by 
Frederick C. Shattuck, A. M., M. D., Instructor in the Theory and Prac- 
tice of Physic, Harvard Medical School, etc. 

With in Illustrations. 8vo, 981 pages. Cloth, $6.00; sheep, $7.00. 

" The above work, which is new to most of our 
readers, has achieved great success in Germany, hav- 
ing reached the third edition in a very short time. 
It has been introduced as the text-book on medicine 
in the Harvard Medical School. The work is espe- 
cially commendable in its treatment of nervous dis- 
eases, which are dealt with fully, concisely, and 
clearly. The pathology of disease, as might be ex- 
pected from so eminent a teacher, has received due 
and careful attention, and this is another strong 
feature of the work. The author gives in this work 
the results of the experience and observation of more 
than six years' active work in the medical clinic in 
Leipsic. We heartily commend the work to the at- 
tention of our readers." — Canada Lancet. 

" In spite of the fact that within the last year or 
two so many excellent works on general medicine 
have appeared, we think there will be found a place 
for the volume before us. The best part of the book 
is the section devoted to nervous diseases. The va- 
rious affections of the nervous system are discussed 
in a very concise way, together with the most recent 
discoveries in neuro-pathology. The translators 
have done their work well, and the editor has made 
a number of important additions. Altogether the 
book is a very valuable contribution and compilation, 
and will be useful both to teacher and practitioner." 
— Maryland Medical Journal. 

" The work before us is one that is peculiarly at- 
tractive to the student of medicine, not only on ac- 
count of the well- delineated German plans of treat- 
ment, but especially for the clear and accurate pa- 
Dr. Shattuck states that he is acquainted with no 
work which treats of the diseases of the nervous system, in which our knowledge has advanced so rapidly 
of late years, so fully, concisely, and clearly. The style is clear for a German work, which as a rule do 
not make models in this particular. The translators have overcome the difficulties of the original so suc- 
cessfully that they have made it a decidedly agreeable text-book. The book is extremely popular in Ger- 
many, having reached the third edition in a comparatively short time, and we do not doubt but that its 
popularity in America will soon be assured." — Mississippi Valley Medical Monthly. 




Fig. 78. — Spasm of the right Splenius Capitis. 
(From Duchenne.) 

thology given by the author in almost all diseases. 



" I like it so well that I have commended it to 
my class and have called special attention to its 
three hundred pages devoted to the nervous system, 
bringing to date all the knowledge which the last ten 
years, more than many centuries past, have brought 
to the use of the profession. "— H. D. Didama, 
M. D., Professor of the Principles and Practice of 
Medicine and Clinical Medicine, College of Medi- 
cine, Syracuse University. 

"I consider it the best text-book of medicine 
with which I am acquainted. The part on nervous 
diseases is so excellent that I shall recommend the 
whole book to my class as a text-book on diseases of 
the nervous system." — Henry Hun, M. D., LL. D., 
Dean of the Faculty and Emeritus Professor of the 
Institutes of Medicine, Albany Medical College. 

"Of the German text-books of practice that 
have been translated into English, Professor Strum- 
pell's will probably take the highest rank. Between 



its covers will be found a very complete and sys- 
tematic description of all the diseases which are 
classed under the head of internal medicine. Un- 
like most of the larger works on practice, we do not 
find the preliminary discourse on general pathologi- 
cal subjects, an omission which is very much to be 
commended, because there are at the present day so 
many special treatises upon pathological subjects 
that there is no longer a necessity for such a section 
in a work of this kind. While it is impossible to 
refer to all these particularly, we may call attention 
to the chapter on Typhoid Fever as being especially 
valuable, not only on account of the advanced views 
in regard to the pathology of that disease, but also 
because of the careful description of its clinical his- 
tory and of its treatment. Taken altogether, it is 
one of the most valuable works on practice that we 
have, and one which every studious practitioner 
should have upon his shelves." — New York Medical 
Journal. 



D. APPLETON &* CO:S MEDICAL WORKS. 



49 




Fig. 390. — Making Plantar Flap. 



A MANUAL OF OPERATIVE SURGERY. By Joseph 

D. Bryant, M. D., Professor of Anatomy and Clinical Surgery, and Asso- 
ciate Professor of Orthopaedic Surgery in Bellevue Hospital Medical Col- 
lege ; Visiting Surgeon to Bellevue Hospital, and Consulting Surgeon to the 
New York Lunatic Asylum and the Out-Door Department of Bellevue 
Hospital. 

New edition, revised and enlarged. With 793 Illustrations. 8vo, 530 pages. Cloth, 

$5.00; sheep, $6.00. 

"The apology given by the author, if any apology be g 

needed for the appearance of so excellent a work, is the fre- # 

quent request on the part of those whom it has been his pleas- '■■■v'J 

ure to instruct in operative surgery during the past few years, 
to make a book based somewhat on the plan he has employed 
in teaching this subject. We have perused this work with 
great pleasure and profit, and can bear testimony to the care 
and attention which the author has bestowed to make the book 
a benefit to his co-workers in the same field. The cuts are 
numerous and well executed, and the text clear and well 
printed. The various operative procedures are clearly and 
concisely described, and the results of the various operations 
briefly stated. The chapter on the treatment of operation 
wounds is worthy of special mention. The work is fully 
abreast of the most recent advances in operative surgery, and 
we have much pleasure in recommending it to our readers." — 
Canada Lancet. 

" The author of this work seems to know how in the brief- 
est space to give the student of surgery the aid necessary ' to 
acquire established facts,' and this is an important point in a 
bock of this kind. The text is most fully illustrated, and 
brings the subject to date, and it will be found useful in the 
sphere to which it belongs " — New York Medical Times. 

" The work of Professor Bryant, while it does not pretend to be a rival of the larger works or systems 
of surgery, is of its kind a most excellent book. Theories and doubtful methods of operating find no 
place in the volume. It is rather to known facts and established procedures that the author has limited 
his labor, and the judgment which he evinces in selecting from the various methods of operating in sur- 
gical cases is generally of a most reliable nature ; indeed, it is this selecting from many proposed proced- 
ures, which are usually met with in the larger surgical works, that much of the value of Professor Bry- 
ant's book depends, and in this respect the book becomes a very able aid to the inexperienced surgeon. 

The scope of the work 
includes most of the 
surgical diseases, and 
the operative meth- 
ods for their relief or 
cure. The operations 
peculiar to the female 
sex, and the surgery of 
the eye and ear, are 
not considered in the 
book. ... In conclud- 
ing our notice of Pro- 
fessor Bryant's book, it 
remains for us to con- 
gratulate him upon the 
successful result of his 
labor. He has written 
a very able and reliable 
surgical work, one that 
may be consulted both 
by surgeon and stu- 
dent, and one that con- 
tains all the more im- 
portant advances of 
modern surgery. The 
pub'ishers' part of the 
work has been well 
done, and the numer- 
ous illustrations add 
much to the value of 
the volume." — Thera- 
peutic Gazette. 
Fig. 459. — Compressing Femoral Vessels. 




- Q D. APPLE TON &* CO:S MEDICAL WORKS. 

PRACTICAL SUGGESTIONS RESPECTING THE 

VARIETIES OF ELECTRIC CURRENTS AND THE USES OF 
ELECTRICITY IN MEDICINE, with Hints relating to the Selection 
and Care of Electrical Apparatus. By Ambrose L. Ranney, M. D., Pro- 
fessor of Nervous Diseases in the Medical Department of the University of 
Vermont ; Professor of the Anatomy and Physiology of the Nervous System 
in the New York Post-Graduate Medical School and Hospital, etc. 

l6mo, 147 pp., with 44 Illustrations and 14 Plates, as an aid in treating morbid states of the motor 

or sensory apparatus. $1.00. 

" It is clearly written, quite practical in tone, and "It presents in a condensed form the latest views 

offers an excellent epitome of the subject."— Medi- on this important subject. Numerous illustrations 

cal and Surgical Reporter. increase the clearness with which the author presents 

his subject. In this form it is more conveniently 

"This is a useful little work, presenting m a reache d ; . . . it is also more conveniently arranged 

brief way the subject of electro-technique and elec- than it is likely to be in a large work on the diag . 

tro-therapeutics."— Medical Record. nosis and treatment of nervous diseases."— Ameri- 

" It will be found a valuable guide to those wish- can Lancet. 

ing to make use of this powerful remedial agent in „ author ' s vie ws are clear-cut, sharply de- 

the treatment of diseases.' -7 exas Courier-Record fine ^ and presented in a concise manner, which 

°f Medicine. gives' the reader a crystal-like conception of what he 

"We recommend this little volume to all who attempts to convey."— Medical Herald. 

are desirous of studying the simplified elements It „ k . h outgrowth G f an ex 
is well illustrated and not too voluminous."— North 



Carolina Medical Journal. 



tensive practice and of lectures delivered on the ap- 
plication of electricity to disease. It is full of prac- 



" For the practitioner who wants brief directions tical hints and many valuable cuts, illustrating the 

where to put the positive pole and where the nega- author's methods." — Denver Medical Times. 
tive, this is the book." — Medical Press of Western 

New York. "The title of this work sufficiently indicates its 

sphere, and all we need say of it is that it is emi- 

" The author is well known as an accomplished nen tly practical and worthy of a place as a text-book 

writer and teacher on nervous diseases, and his con- j n this important and rapidly developing department 

sciousness that much depends, in neurology, upon a f medical practice. "—New York Medical Times. 
knowledge of electricity and electrical appliances, 

induced him to prepare this very useful and timely "The hints contained in it embrace the later 

work, for the benefit of those desiring to use this ideas upon the best electrical apparatus, and the mode 

agent scientifically and successfully in their general of its application in different diseased conditions." — 

practice." — College and Clinical Record. Hahnemannian. 

GYNAECOLOGICAL TRANSACTIONS, VOL. VIII. Be- 

ing the Proceedings of the Eighth Annual Meeting of the American Gynae-* 
cological Society, held in Philadelphia, September 18, 19, and 20, 1883. 
8vo, 276 pp. Cloth, $5.00. 

GYNAECOLOGICAL TRANSACTIONS, VOL. IX. Be- 

ing the Proceedings of the Ninth Annual Meeting of the American Gynaeco- 
logical Society, held in Chicago, September 30, and October 1 and 2, 1884. 
8vo, 408 pp. Cloth, $5.00. 

GYNECOLOGICAL TRANSACTIONS, VOL. X. Being 

the Proceedings of the Tenth Annual Meeting cf the American Gynaeco- 
logical Society, held in Washington, D. C., September 22, 23, and 24, 1885. 
8vo, 357 pp. Cloth, $5.00. 

GYNAECOLOGICAL TRANSACTIONS, VOL XI. Be- 

ing the Proceedings of the Eleventh Annual Meeting of the American Gynae- 
cological Society, held in Baltimore, September 21, 22, and 23, 1886. 

8vo. Cloth, $5.00. 



A Text-Book on Surgery: 

GENERAL, OPERATIVE, AND MECHANICAL. 
By JOHN A. WYETH, M. D., 

Professor of Surgery in the New York Polyclinic ; Surgeon to Mount Sinai Hospital, etc. 
Price, Buckram, uncut edges, $7.00; Sheep, $8.00; Half Morocco, $8.50, 



SOLD BY SUBSCRIPTION ONLY. 



This work, consisting of seven hundred and sixty-nine pages, and containing seven 
hundred and seventy-one illustrations, of which about fifty are colored, is one of the most 
beautiful and unique, and at the same time one of the most complete, works on general 
surgery ever published. 

It is printed in clear, large type on a superior quality of paper, and the book, large 
without being bulky, is in a shape to be easily handled. The illustrations are executed 
with especial reference to the accurate anatomy of the parts represented ; the relations of 
bones, muscles, nerves, and vessels to adjacent structures ; and lines of incision are indi- 
cated in operations about the joints and articulations, thus explaining and simplifying 
their descriptions in the text. The colored illustrations which depict the more important 
operations, especially with reference to the large arteries, constitute a novel and very im- 
portant feature of the work. 

The following brief synopsis will convey an idea of the plan of the work : 

As a preliminary to the consideration of the various operations the author thoroughly 
discusses the methods of preparing the different antiseptic surgical dressings, ligatures, 
sutures, solutions, drains ; the materials for bandaging, with illustrated instructions as to 
the manner of applying bandages in the various forms employed in different parts of the 
body ; anaesthesia, both local and general, including the employment of cocaine as a local 
anaesthetic ; the use and method of administering ether and chloroform ; instruments and 
their uses ; haemostasis and the after-treatment of cases. 

Inflammation, its causes and methods of treatment ; wounds and the manner of closing 
them ; transfusion, poisoned wounds, burns and scalds, gangrene, and the various surgical 
lesions are thoroughly considered and their appropriate treatment given. 

Amputations, with full and minute details of the manner of performing them, and the 
different methods employed, constitute an important chapter in the book. All the prin- 
cipal operations are illustrated by colored engravings made from direct tracings of frozen 
sections on the cadaver. 

The section devoted to the arteries and the procedures necessary in ligating them is 
one of the most important and most beautifully illustrated portions of the work. The 
woodcuts showing the relation of the parts involved in tying the important arteries are 
colored, and their anatomy is depicted in a wonderfully clear and accurate manner. 

Surgical diseases and surgery of the bones ; surgery of the articulations, regional 
surgery, including the common operations on the eye, ear, and jaws : tumors about the 
neck, thyreotomy, laryngotomy, tracheotomy, and cesophagotomy ; the surgery of the 
thorax and abdomen ; and operations on the rectum and anus are dealt with in the light 
of the most advanced surgical knowledge. 

Genito-urinary surgery and specific lesions receive a due share of attention, as do de- 
formities of the spine and extremities, and malignant tumors and growths. 

This work, written by an accomplished surgeon of wide experience, and fully abreast 
of the highest attainments in surgical knowledge and science, presents to the student and 
practitioner a means of acquainting himself with modern surgery as it is taught and prac- 
ticed by a master of the art, and will enable him to prepare himself for the intelligent 
performance of many operations, and to treat many surgical lesions with which he may 
feel he is not sufficiently familiar. 

D. APPLETON & CO., Publishers, 

1, 3, & 5 BOND ST., NEW YORK. 



52 



INDEX. 



Air, Essays on the Floating Matter of the ..... 25 
Anaesthesia, Local, in General Medicine and 

Surgery 47 

Anatomy, of the Nervous System 26 

Physiology and Hygiene, The Essentials of. 42 

The Comparative, of the Domesticated 

Animals 10 

The, of Invertebrated Animals 20 

The, of Vertebrated Animals . . . .• 15 

Aorta, Diseases of the Heart and Thoracic 42 

Bacteriological Investigation, The Methods of . . 19 

Barker. On Sea-Sickness 1 

The Puerperal Diseases 1 

Bartholow. A Treatise on the Practice of Medi- 
cine 4 

On the Antagonism between Medicines 5 

Treatise on Materia Medica and Therapeu- 
tics 3 

Bastian. Paralyses: Cerebral, Bulbar, and Spi- 
nal 37 

Paralysis from Brain Disease 1 

The Brain as an Organ of Mind 3 

Bennet. On the Treatment of Pulmonary Con- 
sumption 5 

Winter and Spring on the Shores of the 

Mediterranean 5 

Bile, Jaundice, and Bilious Diseases, On the... 17 
Billings. The Relation of Animal Diseases to 

the Public Health 43 

Billroth. General Surgical Pathology and Thera- 
peutics 6 

Body and Mind 22 

Bones, A Treatise on Diseases of the 24 

Brain Disease, Paralysis from 1 

Exhaustion, A Treatise on 41 

The, and its Functions 34 

The, as an Organ of Mind 3 

Bramwell. Diseases of the Heart and Thoracic 

Aorta 42 

Breath, The, and the Diseases which give it a 

Fetid Odor 17 

Bryant. A Manual of Operative Surgery 49 

Buck. Contributions to Reparative Surgery .. . 12 

Carpenter. Principles of Mental Physiology. . . 2 

Carter. Elements of Practical Medicine 37 

Chauveau. The Comparative Anatomy of the 

Domesticated Animals 10 

Chemical Technology, A Hand-book of 31 

Chemistry, Inorganic ^3 

Organic 33 

Short Text-book of Organic 2 

The, of Common Life 12 

Children, A Practical Treatise on Diseases of . . . 36 

Children's Diseases, Compendium of 28 

Club-Foot, A Practical Manual on the Treat- 
ment of 28 

Combe. The Management of Infancy 1 

Consumption, on the Treatment of Pulmonary. 5 

Corfield. On Health 2 

Corning. A Treatise on Brain-Exhaustion 41 

Local Anaesthesia in General Medicine and 

Surgery 47 

Davis. Conservative Surgery .- n 

Deformities, A Treatise on Oral 16 

Dermatology, A Manual of 45 

Diseases, The, of Sedentary and Advanced Life. 46 

Down. Health Primers 19 

Ear, The Diagnosis and Treatment of Diseases 

of the 46 

Education, Physical ... 23 

Electricity in Medicine, The Uses of 50 

Elliot. Obstetric Clinic 7 

Emergencies, and How to Treat them 14 

Evetsky. The Physiological and Therapeutical 

Action of Ergot 6 

Eye, A Hand-book of the Diseases of the 42 



PAGE 

Flint. Manual of Chemical Examination of the 

Urine in Disease 7 

Medical Ethics and Etiquette 44 

Medicine of the Future 47 

On the Physiological Effects of Severe and 

Protracted Muscular Exercise *. . . 7 

Text-bock of Human Physiology 8 

The Physiology of Man 9 

The Source of Muscular Power 7 

Foods 31 

Fothergill. The Diseases of Sedentary and Ad- 
vanced Life 46 

I Fournier. Syphilis and Marriage 9 

Frey. The Histology and Histo-Chemistry of 

Man 11 

Friedlaender. The Use of the Microscope 44 

Gamgee. Yellow Fever a Nautical Disease 11 

Genito-Urinary Organs, Surgical Diseases of the. 31 
Gross. A Practical Treatise on Tumors of the 

Mammary Gland 13 

Gutmann. Watering-Places and Mineral Springs 

of Germany, Austria, and Switzerland 28 

Gynaecological Transactions. Vols. VIII, IX, X, 

and XI 50 

Hamilton. Clinical Electro-Therapeutics 20 

Hammond. A Treatise on Insanity 38 

A Treatise on the Diseases of the Nervous 

System 14 

Clinical Lectures on Diseases of the Nerv- 
ous System 15 

Harvey. First Lines of Therapeutics 17 

Health 2, 29 

A Ministry of, etc 27 

And How to Promote it 22 

Primers. 19 

Heart and Thoracic Aorta, Diseases of the 42 

Histology and Histo-Chemistry, The, of Man.. 11 
Hoffman and Ultzmann. Analysis of the Urine. 20 

Hospital Reports. — Bellevue and Charity 30 

Hospitals 33 

Howe. Emergencies, and How to Treat them. 14 
The Breath, and the Diseases which give it 

a Fetid Odor 17 

Hueppe. The Methods of Bacteriological In- 
vestigation 19 

Huxley. The Anatomy of Invertebrated Ani- 
mals 20 

The Anatomy of Vertebrated Animals 15 

Hygiene, Physiology, and Anatomy, The Essen- 
tials of 42 

Infancy, The Management of 1 

In-Knee, Medical and Surgical Aspects of 34 

Insanity, A Treatise on 38 

Jaccoud. The Curability and Treatment of 

Pulmonary Phthisis 44 

Johnson. The Chemistry of Common Life. ... 12 
Joints, Lectures on Orthopedic Surgery and Dis- 
eases of the 29 

Jones. Practical Manual of Diseases of Women 

and Uterine Therapeutics 41 

Journal, The New York Medical 36 

Keyes. The Tonic Treatment of Syphilis 12 

Kingsley. A Treatise on Oral Deformities 16 

Liegg. On the Bile, Jaundice, and Bilious Dis- 
eases 17 

Letterman. Medical Recollections of the Army 

of the Potomac 22 

Life, Diseases of Modern 28 

The Diseases of Sedentary and Advanced. . 46 

Little. Medical and Surgical Aspects of In-Knee. 34 

Loring. A Text-book of Ophthalmoscopy 46 

Lusk. The Science and Art of Midwifery 18 

Luys. The Brain and its Functions 34 

Mammary Gland, Tumors of the 13 

Markoe. A Treatise on Diseases of the Bones. 24 
Materia Medica and Therapeutics, Elements of. . 24 



INDEX.— (Continued.) 



53 



Materia Medica and Therapeutics, Treatise on . . 3 

Matter, the Floating, of the Air, Essays on 25 

Maudsley. Body and Mind 22 

Responsibility in Mental Diseases 22 

The Pathology of Mind 21 

The Physiology of the Mind 23 

McSherry. Health, and How to Promote it 22 

Medicine, A Text-book of 48 

A Text-book of Practical 25 

A Treatise on the Practice of 4 

Elements of Modern 45 

Elements of Practical 37 

of the Future 47 

Memory, Diseases of 38 

Mental Diseases, Responsibility in 22 

Microscope, The Use of the, in Clinical and Pa- 
thological Examinations 44 

Microscopy, An Atlas of Clinical 45 

Midwifery, A Manual of 32 

The Science and Art of 18 

Mind, Body and 22 

The Brain as an Organ of 3 

The Pathology of 21 

The Physiology of the 23 

Monthly, The Popular Science 39 

Muscles and Nerves, General Physiology of 34 

Neftel. Galvano-Therapeutics 23 

Nerves, General Physiology of Muscles and 34 

Nervous Diseases, A Treatise on 44 

Nervous System, A Treatise on the Diseases of the 14 

Clinical Lectures on Diseases of the. . . 15 

The Applied Anatomy of the 26 

Neumann. Hand-book of Skin Diseases 21 

Niemeyer. A Text-book of Practical Medicine. 25 

Nightingale. Notes on Nursing 24 

Nursing, A Text-book of 47 

Notes on 24 

Obstetric Clinic 7 

Ophthalmoscopy, A Text-book of 46 

Osteotomy and Osteoclasis 40 

Oswald. Physical Education ; or, the Health- 
Laws of Nature 23 

Ovarian Tumors 24 

Ovaries, Diseases of the 39 

Paralyses : Cerebral, Bulbar, and Spinal 37 

Paralysis from Brain Disease 1 

Pathology and Therapeutics, General Surgical. . 6 

of Mind, The 21 

Peaslee. Ovarian Tumors- 24 

Pereira. Elements of Materia Medica and 

Therapeutics 24 

Peyer. An Atlas of Clinical Microscopy 45 

Phthisis, The Curability and Treatment of Pul- 
monary 44 

Physiology, General, of Muscles and Nerves. . . 34 

Hygiene, and Anatomy, The Essentials of. 42 

Principles of Mental 2 

Text -book of Human 8 

The, of Man g 

The, of the Mind 23 

Pomeroy. The Diagnosis and Treatment of 

Diseases of the Ear 46 

Poore. Osteotomy and Osteoclasis 40 

Puerperal Diseases, The 1 

Pyuria ; or, Pus in the Urine 43 

Quain. A Dictionary of Medicine 34 

Ranney. The Applied Anatomy of the Nerv- 
ous System . 26 

Practical Suggestions respecting the Uses 

of Electricity in Medicine 50 

Receipts, Cyclopaedia of Practical 10 

Rectum, Lectures on Diseases of the 30 

Richardson. A Ministry of Health 27 

Diseases of Modern Life 28 



PAGE 

Robinson. A Manual of Dermatology 45 

Roscoe and Schorlemmer. A Treatise on 

Chemistry 33 

Rosenthal. General Physiology of Muscles and 

Nerves 34 

Sanitary Information, Hand-book of 43 

Sayre. A Practical Manual on the Treatment 

of Club-Foot 28 

Lectures on Orthopedic Surgery and Dis- 
eases of the Joints 29 

Schroeder. A Manual of Midwifery 32 

Sea-Sickness, On 1 

Simpson, Sir James Y. The Posthumous 

Works of 31 

Skin-Diseases, Hand-book of 21 

Smith. Diseases of Memory 38 

Health 29 

On Foods 31 

Steiner. Compendium of Children's Diseases. . 28 

Stone. Elements of Modern Medicine 45 

Strecker's Short Text-book of Organic Chem- 
istry 2 

Striimpell. A Text-book of Medicine 48 

Surgery, A Manual of Operative 49 

Conservative 11 

Contributions to Reparative 12 

Lectures on Orthopedic, and Diseases of the 

Joints 29 

Lectures on the Principles of 40 

Swanzy. A Hand-book of the Diseases of the 

Eye, and their Treatment 42 

Syphilis and Marriage 9 

Outlines of the Pathology and Treatment of. 13 

The Tonic Treatment of 12 

Therapeutics, Clinical Electro- 20 

Elements of Materia Medica and 24 

First Lines of 17 

Galvano- 23 

General Surgical Pathology and 6 

Treatise on Materia Medica and 3 

Tracy. Hand-book of Sanitary Information . . 43 

The Essentials of Anatomy, Physiology, 

and Hygiene 42 

Tumors of the Mammary Glands, A Practical 

Treatise on 13 

Ovarian 24 

Tuson. Cyclopaedia of Practical Receipts 10 

Tyndall. Essays on the Floating Matter of the 

Air 25 

Ultzmann, Hoffman and. Analysis of the 

Urine 20 

Pyuria ; or, Pus in the Urine 43 

Urine, Analysis of the 20 

in Disease, Manual of Chemical Exami- 
nation of the 7 

Van Buren and Keyes. A Practical Treatise on 
the Surgical Diseases of the Genito-Urinary 
Organs 32 

Van Buren. Lectures on the Principles of Sur- 
gery 40 

Lectures upon Diseases of the Rectum and 

Surgery of the Lower Bowel 30 

Vogel. A Practical Treatise on the Diseases 
of Children 36 

Von Zeissl. Outlines of the Pathology and 
Treatment of Syphilis 13 

Wagner. A Hand-book of Chemical Technology 31 
Walton. The Mineral Springs of the United 

States and Canada 37 

Webber. A Treatise on Nervous Diseases 44 

Weeks. A Text-book of Nursing 47 

Wells. Diseases of the Ovaries. 39 

Wylie. Hospitals 33 

Yellow Fever, a Nautical Disease. . , 11 



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